0900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT N ONLY
I
BUI LDI NG PROJECT I DENTI FICATION J PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0 O
ADORE s 9
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL O9
oe ER'S ppy��'' - PLAN CHECK VALIDATION
NAME o TV. ELECTRIC PERMIT FEE
L PXD
CONT ACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
�0, 1( [', LHC NGZqq 2/.r7 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS \
PHONEZGI -�>E PANELS 5.00 DATE OF APPLICATION
ARCH( ECT SIGNS 6.00 PLAN WCHECK P.G.NO,
On
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 nn
AvvucANTS
ADDRESS MOTORS SEE FEE SCH.
v/,L(,.(fCJC7 0
SERVICE CHANGE 10.00
o O LICENSED CONTRACTORS DECLARATION
Ip u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Ha a (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m Professions Code; tbmy license is in full force�sipd,e[�ect
z o m- License Class Lia Number (S 7 O
9 w E Date^I-. I . .-/. !-��' Comructor
a >< s d q`r` _ S 1 a L7� BUILDING PERMIT
It w 4 'OWNER-BUILDER DECLARATION
F.
;I r I hereby affirm that I am exempt from the Contractor's License MISC. - REFER TO ORD INFORMATION
ae , u, Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6 00 VALUATION S/FT.
Code:Any city or county which requires permit to construct,alter.
am ELEC.CONTR. LIC.N0.
¢ < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC. O CJ
- D W requires the applicant for such permit to file a signed statement that TOTAL - PERMIT�T►Oy�F
K
$ he is licensed pursuant to the provisions of the Contractor's License AW"L 'r
H z r Law ossa and
Professions
Codeng with Section is exempt
the of o of the
a Business and Professions exemption.
or that he is exempt therefrom and CITY. - PLUMBINO,PERMIT'. REE'.
fio
tc I- the basis for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR. e
by any applicant fora permit subjects the applicant macivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mom than five hundred dollars IS5001.1:
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
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. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 / SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such'in
Prove-
Bentsare not intended oroffered for Sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 4,00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES B CON PB Omer
prove for purpose of sale.). INDUST T 20.00
❑ L as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKL S- 1 I .B. 5.00 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 SPR (EA.) 1.00
contracts for such projects with a contmetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITAR -S ORM EA.200ft/6.00 'y TRACT No. PARCEL No.
❑ 1 um exempt under Sec. .BARC.for this WATER HEATE T 4.00
reason
Date Owner WATER SVSTE - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereor(Sec.3800,Lab C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE BPRINK ENERGY T 2
Z 2 ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
O Applicant v N� v N�
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.00NTR. LIC.NO. PLG. (a fl
0 Z (This section need not be completed if the permit is for one TOTAL L�O v❑ N� v ❑ N�
hundred dollars IS 100)or less.) -
U O I certify that in the performance of the work for which this per- -MECHANICAL PERMIT - FEE FEE BUMMARV
U. F mit is issued.1 shall not employ any person in any manner so as to
becom��syybbfe�cyS0{he Worken'Co pe ti La�6 f Califamia.
U Off/ Date!=APPLICANT:
f ,'r2--/f- . BUILDING
} u1` EE pp ALTER OR ADDTO MECH. 4.00
Z NOTIC TO APPLICANT: If,after making this Certificate of Ex-
F emption,you should became subject to the Workers'Compensation APPLIANCE 4.00 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 10,000QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE .y7l
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Ci,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Na
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING 3 0) cv
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4,00 ,
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100.000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Babilitip,judgments, costs and expenses which CONST.TAX
may in an PERMIT ISSUANCE 3.00
y y ace^J�`against said City i onseque of the
gtanOn of spermµ'- MECH.CONT. LIC.N0. MECH.
�,� /� �.. 7 % TOTAL TOTAL' / c c.
Signature of Applicant/Contractor �a -
OFFICE COPY