10879 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI (CATION PERMIT NumRER
BUILDING I APPLICATION & PERMIT O
ADDRESS I' 1
c�•Jq O QQsI BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - 879
PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
PHONE
ANTRacrDRs
NAME UTLETS-SWITCHES•RECEP 10.00/1.00
Ah df
^ry/.t/ sec.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOWS /IH, APPLIANCES-RESIDENTIAL 4.00
ADDRESS /] /G/r�f I��S G�
D I-o"q/ /J'�/�E vHONF /G�- PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
EBB rs . MOTORS SEE FEE SCH.
APPLICA
SERVICE CHANGE 20.00 / 1
_02
0o LICENSED CONTRACTORS DECLARATION
a u w I hereby affirm that I um licensed under provisions of Chapter 9 ISSU NCE DATE
y a (commenting with Section 70001 of Division t of the Business and BLDG. ELECT. PLG. MECH.
F w i Professions Code nd lily liacasc is in full fno,-a fe C ❑ 1 ❑ ❑ ❑
z O m- License ass J Lic.Number _
z - Uate Contractor -
st x 5 .�i BUILDING PERMIT
rC w u OWNIi R-BUILDER La .ARA'rION INFORMATION
woa MISC.- REFER TO ORD
3 H 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F a-p j Law for lire following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, ID
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC,CONTR. LIC.NO. ELEC.
y w m BE requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO (/pr
he is licensed pursuant to the provisions of the Contractor's License pp�
F Z> Law(Chapter 9(commencing with Section 7000)of Division 3 of the W �G'4-dff T E.
< Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 DRIES TYPE CONSTR.
a; m by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00 Mal
of not more than five hundred dollars($500).1:
❑ 1,as owner of theproperty,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their Sole compensation,will do the work,and the Structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotlntendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is Said within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe orhe,
Cl I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct fit. project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a Contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPHN3ATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby nOtrm that I have u certificate of consent to self-insure,
or a certificate of Workers ZONING Compensation Insurance,or certified ENG.SITE NO.
copy thereof(Sec,3800,Lab.C2
Policy No. Company ?/' }'C1/4
0 '❑ Certifiedc py is here lF 'shed. T FI RE SPR INK EN ERGV T-24
Z 2 Cert ifie opy fl wit the city inspection division. -
MISC.- REFER TO ORD.
U A Plicant V❑ N❑ V ❑ N❑
� N C. I7 CATE OFLEXEh1PTIObU WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPIiNSATION IN ANCIi PLG.CONTR. LIC.NO. PLG.
1 O ffhi action need not Be Completed if the permit is for one TOTAL V❑ N❑ v ❑ N❑
Z lundred dollars IS 100)or NSO
U O I certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued.I shall not employ any person in any manner so as to
Ubecome subject to the Workers Compensation Laws of California.
U y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ��
} US NOTICE TO APPLICANT': If,after making this Certificate of Ex-
I- Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0000F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
The 3097 eCiv. 0 once of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct, 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter_ upon tire
above-mentioned property for inspection purp.wS. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities, ""at" costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
mBy any way ecme a I t said City in consequence of the
grapfoo of this P . MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
g tare of App(cant/ it Data
I OFFICE COPY