09983 APPLICANT TO FILL IN INFORMATION WITHINRED LINES - USE BALLPOINT PEN ONLY
BU LDING PROJEC DENTIF ION PERMITNUMBER
BUILDING APPLICATION & MIT O
AODRES
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'3 PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
/V AWS PHONE
CONTRACTOR'S �q
'�V OUTLETS 10.00/1.00
NAME ,
ilc.No J60J/ 1 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'5 8oWWg4#F,6 ws
' ADOREss APPLIANCES-RESIDENTIAL 4.00
ouov X PHONE PANELS ' 10.00 DATE OF APPLICATION
o.C,ullcl PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No,
ENGIry EER �I . . ,
444-5/N// Tic.NO. SIGNSTRANS. 3.00
AR H.Ess ENG' IM
SPECIALCIRCUIT 5.00 IOATION
ZIP EMP.METER OR POLE INS. 20.00 C �pgE
APPLICANT rs ��- /r2Aa 6301. - MOTORS- SEE FEE SCH. OCT 99tU�JJ
AooREss .•
A6997- &90 -vV SERVICE CHANGE 20.00 Cliy W o{ CaPerIno
'02
0o LICENSED CON"fRACfORS DECLARATION' TEMP.POLE 30.00
a u 1 hereby affirm that I am licensed under provisions of Chapter9
H rt H (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
F N z Professions Code, my license is in full fore and effect BLDG. ELE PLG. MECH.
oz m o License Class_ __Lic.Number I y / El 0
Date /.y��(f.�`? �C�ntraca 0-� _
W ¢w a '•'( Wi'1 NI:R;BUILDER DLCLAR 'ION BU DING PERMIT
° - MISC.-• REFER TO ORD INFORMATION
K
; LL Thereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
u° 4 Law for the following reason.(Sec.703 L5,Business and Professions
N -I Code:Any city or county which requiresa permit to construct,alter, PERMIT ISSUANCE 10.00
- rt ¢ as improve,demolish,.or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
n
°¢ requires the applicant for such permit to file a signed statement that TOTAL
esu he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
ar Law(Chapter 9(connnencing with Section 7000)of Division 3 ofthe
4 c Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 '
STOVES
t g ? by:toy applicant for a permit subjects the applicant to a civil penalty • YPE CONSTR.
of not more flumfive hundred dollars($500f) ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,'AREA,CON D. 5.00
Code:The Contractor's Liceere 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 TOTAULREAGE
• himself or through Itis own employee,,provided that such improve-
mends are not intended or offered for sole.If,however,(lie building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner,
builder will have the burden ofproving that he did not build or am. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove fors owner of sale.). INDUSTRIAL WASTE INTER. 30.00 E t❑ Ory ❑ Other❑
❑ L c owner of the property,am project
(Se contracting with
licensed contractors to construct the Project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORBPARCELNO.
and Frowner ns Code:The Contractor's License Law does not apply ,
to contracts
cts for
of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 6(EA.) 1.00
the Co is actor's h projLicense
with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA,200tt/10.00
iliac Contractor's Licmue Luw, TRACT N0. PARCEL N0,
rem❑mll am exempt under See. ,li.&P.C.for this WATER HEATER W/VENT ' 6.00
Owner Date WATER SYSTEM 5.00 ACO-GATE ACC.FILE NO.
WORK Ii RS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy tlmrcol-(Sec.3HB0,U1,C). - -
Policy Nc, Company
0 ❑ Certified copy is hereby famished. - ' FIRE SPRINK ENERGY T"24
Z Z ❑ Certified copy is fled with the city inspection division.
PO Applicant MISC.- REFER TO ORD. Y � 'N[2 I Y'Q N[]
CERTIFICATE OF EXFMPRON F ROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE � A.LU.C.
LU �( COMPENSATION INSU RANCE PLG.CONTE. LIC.NO. PLG.
CL O ('This section need not be completed if the Permit is for one TOTAL- v N Y ry
D Z hundred dollars IS 100)or Icss.)
L) O I certify 0..t in the performance of the work For.)act,this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL E_ ndl-Is issued,I stall not employ any person in any..tanner so as to
O W become subject to the Workers'Compensation Laws of California.
0. DireApplicant BUILDING
�- W NOTICE 10 APPLICANT: 11',after....king this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 ,
Z Iemption,you should become subject to the Workeri Compensation APPLIANCE
provisions the Labor Code, you must forthwith comply with 5.00 PLAN CHECK
- FEE
U such provisionspr this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNITIOVER 10=C-RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance o1'the work for which-fli s permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - - - -
-Lender's Address- H EATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. information is correct. I agree to comply with all city and county - PLUMBING
orlinances and state laws relating to building construction, and BOILER-COMP 13,H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives h ofof this city to es.enter upon the
above-mentioned property(or inspection PurposesBOILER-COMP(Over 100,0008TU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST..TAX
may in any way accrue against said City in consequence of the
gmntingofthis permit. - MECH.CONT. CLIC.NO. MECH.
TOTAL, TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY