09976 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL 176INTIPEN ONLY
- BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION &PERMIT
ADDRESS
,W ,qyE BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 09976
OWNER'S vv - PLAN CHECK VALIDATION
I NAME OTY. "ELECTRIC PERMIT •'FEE
PHONE r J.
rvoN rolls OUTLETS-SWITCHES-RECEP 10.00/1.00
EQ O y`, ti LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S 360 APPLIANCES-RESIDENTIAL 4.00
Ad-
//(/wry
d dex 'Rip j� PANELS 10.00 DATE OF APPLICATION
OR
RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS, 3.00
ARCH.all ENG. PERMIT VAELIOATIOONN
ADDRESS SPECIAL CIRCUIT 5.00 PPAAAA 11g�
ZIP EMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH. FEB 4
ADDRESS OREBS lqtE-��86
SERVICE CHANGE 20.00
0 o a LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of
Co ff100
a u I hereby affirm that'l am licensed under provisions of Chapter 9 ISSUANCE D t l
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. LG. MECH.
r m i Professions Code,yyyyd rrWfieem is in full force q ft' / /(f
o i w License lass Lic. in
/ 6 ( D� ❑ ❑
Uate _S- Contfacfor s�0/ZA/L7"
Q y J '
X IC m Q OWNER-BUILDER DECLARAT11 . BUILDING,PERMIT"
A o A o
w ; w I hereby affirm that I am exempt from the Contractor's License MISC.- EFER TO ORD INFORMATICII
Y.O¢ Law far the fallowing reason.(Sec.7031.5,BuslnesSand Professions VALUATION $/FT.
r - w PERMIT ISSUANCE 10.00 'a¢
BEw Y Code:Any any structurep prior ttoconsmuce,also¢ BE ¢O improve,demolish,or repair any structure,prior to its issuance,also E .CONTR. LIC.N EC.
u squires the duaapplicant for such permit to fill a signed statement that TAL pa PERMIT A w m he is licensed pursuant to the provisions of the Contractor's License
H z Law(Chapter 9(commencing with Section 7000)of Division 3of the /
i i 4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT 'FEE
ICI-$ thethsis forthealleged exemption.Any violation of Section703L5 STORIES TYPE CONSTR.
by any ore thafora permit subjects the applicant toacivil penally ALTER-DRAIN St VENT-WATER (EA.) 5.00 .
of not more than five hundred Dollars($5001.):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 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. 5.00
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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such'top rzrve-
memsamHot intended oroffered for sale.Il',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden o'proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 UILOING USE
prove for purpose of s(litJ' INDUSTRIAL WASTE INTER. 30,00 RES ❑ ❑N IRS❑ Other❑
❑ 1.d as owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codi The Contractor'sbuilds1improv Law Joos not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctort s)licensed pursunnt to SEWER-SANITARY-STORM EA.200ft/10.00
the Col am axe pt Linde Law. TRACT N0. PARCEL NO.
❑ lam exempt under Sec..,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner, Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
AI�VVY'KTIOMPI ,'IOy�,,CC}y1RATION WATER TREATING EQUIP. 5.00
1 her( y affirm hit It ertificate o ouvain to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See C. pony_. i ��
Policy ere Company F/'�P!�
O ❑ Canifiedcopy lsh ruby furnished. FIRE SPRINK ENERGYT Y4
Z Z �Cetlifie f the C i action division.
O iCpfSlicam- � MISC.- REFER TO ORD. Y❑ NE] Y [] N[]
rn CIi RTIPICATIi OE li MI'rION I M WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C,.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CIL O (This section need not he completed if the permit is for one TOTAL Y N� Y ❑ N�
D Z hundred dollar,,(S1010)or less,)
00
1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY '
L H mit is issued,1 shall not employ any person in any manner so as to
U W surs become bject to the WorkeCompensation Laws of California.
G. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 'r0 APPLICANT: It,alter making this Certilicate at Iix-
? emptier,you should become subject to the Workers'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=QF.M.) 4,00
CONS'I'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RMJ 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the 'ork !or which this permit is issued(Sec. MICROFILM
3097,Civ.C.). d�F HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)B.50 ELECTRIC
I certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4,00
. Information n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
information
and stole laws relating l0 building l city action,nd co and
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovementioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
in in an y ac a against said City in conscryrenceinf-the PERMIT.ISSUANCE 10.00
gran !7J/�/TOGO'/ MECH.CONT. LIC.NO. MECH.
ea� TOTAL
Signatrlre of Appli t/Cents:c[ Date
OFFICE COPY