09691 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
gg BUILDING PROJECT IDENTI FICATION PERMIT NUMBER
AOIonENS APPLICATION & PERMIT
Q v x� C.�-.• BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09691
I
OWNER'S , PLAN CHECK VALIDATION
NAME IrC OTY. ELECTRIC PERMIT FEE
I" aer �-VL( 1� PHONE
NAMERAcroR's OIGUTLETSG-SWITCHES-RECEP 10.00/1.00
6
sa'LO L�E3C• c.NO, LHTI
LIC. FIXTURES 10.00/1.00
RODFEss roll's ��� APPLIANCES-RESIDENTIAL 4.00
02 bi�dN PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
AARCH,OR
DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S �• `L✓C n JL
ADDRESS �/.�. J MOTORS SEE FEE SCH.
J! n $6 SERVICE CHANGE 20.00 -� 9 �/^
woo . LICE ED CONTRACTORS DECLARATION TEMP.POLE 30.00 / 1
a i u~Ui• 1 hereby afORn that I am licensed under provisions of Chapter 9 jLe ,0 ISSUANCE///DATE
¢ (commencing with Section 7000)of Division 3 of the Bramesx and BLDG. ELECT. PLG. MECH.
in H y i Professions Code,qDd m 'cense is in full force and e(�erl-,t„n
Z o M License lass `- Lie,N full f El
9 z r w Datc Contractor S1 +x
E ¢ ¢ OWNER-BUILDER DECLARATION `a BUILDING PERMIT
- 0 w u INFORMATION
w-; ,N I hereby affirm that I am exempt from the Contractor's License MISC.- TO ORD ygLUAT10N 5/FT.
F• :O¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANC 10.00 /0.00
Code:Any city or county which requiresa permit to construct,alter,
Y improve,demolish,or re ur an structure,prior to its issuance,also ELEC.CONTIL LIC.NO.
¢ 5 ¢ 0 P P' Y p er /7 ELEC. / .DO
a a D u requires the applicant to,such permit to file a signed statement that I TOTAL 'T PERMIT TO
w y he is licensed pursuant to the provisions of the Contractor's License r ���/�
FZ > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -C
q t o Business and Professions Code)or that he is exempt therefrom end QTY. PLUMBING PERMIT FEE /
it 1- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dg by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mom than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do thework,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 applylo an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenetinlended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or int- . BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Oshm
❑ I,as..net of the properly,am exclusively contracting with ❑ Cl ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS.I.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 contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,BAP.C.For this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ALC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
'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 N0.
copy thereof(Sec.3800,Lab.C.).
Policy No. - Company
O �(} Certified copy is hereby furnished. FIRE BPRINK ENERGY T-24
Z Z �• Certified c p s filed lh the gily I ection division,
Avplicant(_t/p,'g „ f MISC.- REFER TO ORD.
O 4'E/r4 �' y❑ ry❑ y❑ N❑
~ rnPERMIT ISSUANCE 10.00
� CF:RTI FICATE OF EXEMPTION PROM WORKERS' FLOOD ZONE q.L.U.C.
W :x COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
CL a (This section need not be completed if the Permit is for one TOTAL YE] N❑ Y❑ N❑
0 Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the wnrk for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
W mit is issued,I shall not employ any person in any manner so as t0
become subject to the Workers'Compensation Laws of California.
0
Is. Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
N NOTICE.TO APPLICANT: If,after making this Certificate of Ex
H Z emption,you should beconre subject to the Workers'Compensation APPLIANCE . 5,00 PLAN CHECK
provisions of the Labor Code, you.must forthwith Comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 100001C.F.M.) 4.00
CONSTRUCTION LEN DING AGENCY AIR HANDLING UNIT(OVER IO,000C.FM.16.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for,which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50 /
Lender's Address ELECTRIC I C
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n comet I agree to comply with all city end county BOILER•COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction,co my
hereby authorize representatives of this city to enter upon tire BOILER-COMP(Over 100,000 BTU)SEEFEE 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 liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
e Myin any way accrue against sai 'ty in con quence of the
nl g of this permit. ^ MECH.CONT. LIC.NO. MECH.
y TOTAL TOTAL
ture of Applicant/Contractor Dale`
OFFICE COPY
a