09586 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BA POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI _ PERMITNUMSER
as NG APPLICATION & PER
.�( AOORE55 �yH �rroNa 4W4.
'\ f P BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
09586
I OWNER'S ,
OWNIPLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
NTIS7NID &- 5 PHONE;}.
NAME CTOfl'S
rvgmgE Q-/D UTLETS-SWITCHES-RECEP 10.00/1.00
/-TAIL/^! �./�T"C//�-IG Lie,No.9Q;0 • SLIGHTING FIXTURES 10.00/1.00
CONTRACTORS M//
ocroas A 'D3$-I APPLIANCES-RESIDENTIAL 4.00
7 CONTRA q1 5 e
-;") b[O_' PHONE / PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FE7 D.C.N0.
OR '9Z?Ag�/_- sem/ �. PANELS (OVER 200 AMP) 20.00
ENGINEER '--C/
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG. 2"JS F!�-6 S% SPECIALCIRCUIT 5,00 PERMIT VALI DATION
A OOR E55 ✓J
EMP.METER OR POLE INS. 20.00 Q
APPLICANT'S
ADDRESS SOCK. MOTORS PAIDEE FEE SCH. �' ,�(�07•v'F"r"
M/L /2Y7YS e*Lj� .$�-�V SERVICE CHANGE 20.00
00 LIC
ENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Y jAJ
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y rt n (commencing with Section 7000)of Division 3 of the Business and D 1 BLDG. ELECT. PLG. MECH.
H 7 z Professions Cod and my license is in full force and effect O V e
i l2 o License Class /6 Lic.Number
0 Date-Conlructor,$G�P
¢ w OWNER-BUILDER DECLARATION BUILDING PERMIT
w ;LL a 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
u o ¢ Law for the following reason.(Sec.7031.5,Businessand Professions
VALUATION $/FT.
H - H PERMIT ISSUANCE 10.00
E w e Code:Any mulish county whiny Structure permit to
issuance,also V
¢ 2 ¢ 0 improve,demolish,or repair any structure,prior to cls issuance,also ELEC.CONTR. LIC.NeO,..e ELEC.
C,¢ requires the applicant for such permit to Ills a signed statement that JSCOJ✓PJ E1FCVW_ A(gl/p,p-Q•�C TOTAL _� PERMIT TO
n w m u i he is licensed pursuant to the provisions a]the Contractors License
H z
Law(Chapter 9(commencing with Section-7000)of Division 3 ofihe
E i c Business and Professions Code)or that he is exempt ihere(rmn and OTV. PLUMBING PERMIT FEE
w $ the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
by any applicant far a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5,00
of not more than five hundred dollars(3500t):
O I,as owner of the property,or my employees walla wages as BACK F LOW PROTECT.DEVICE 4,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the struclu re is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,CON D. 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 improve-
C meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 '
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that lie did not build or im. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessLAWN 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 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft
the Contractor's License Law. /10,00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec.-.B.&RC.for this
reason WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPHNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate o(consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy there f Sec.3800,La,t"),
Policy No. Company -�+ }�Ff1.GJM
❑ Cert IFKhereby furnished. FIRE SPRINK ENERGYT 24
Z Z life opy is filed with the city inspection division.
01- pit MISC.- REFER TO ORD. Y[:] 'N� v ❑ N�
!2 CG TIVICAT177017 EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD 20N0 A.L.U.C.
UJ ��-__�/� COMPfiNSATION INSURANCE - PLG.CONTR. LIC.NO.
PLG.
11 O (This section need not be completed if the permit is for one TOTAL Y 0 N❑ Y N El
7-) Z hundred dollars IS 100)or less.) 3
L) O I certify that in the performance of the work for whish the per- - Y S i tr dr` y.FEE�SUMMARY
LL F mit is issued.I shall not employ any person in any manner so us Ito QTY. MECHANICAL PERMIT; f FEE# s '
O become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NOTICE '1'0 APPLICAN'P: If,after making this CertificulC of Fix
F ? emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 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 work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leaders Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information i rotate . 1 l agree to comply with all city anti
ordinances air state I a relating to building construction anti
county
anti BOILER-COMPI3 H.P.or 100,000 B.T.U.1 6.00 PLUMBING
hereby authorize representatives ec this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
ma oned property for inspection purpous.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
n / may in any way acct against said City in consequence of the
X/J granting of this perm' . MECH.CONT. LIC.N0. MECH.
NOTAL
Signature ol'Applica /Contmclor Dete TOTAL
OFFICE COPY