9442 APF!L•ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUkLDI NG PROJECT 1 DENTI FICATI PERMIT NUMBER
BUILDING 0 APPLICATION & PER
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL .9442
WNEE'S 11 PLAN CHECK VALIDATION
"nm CITY. ELECTRIC PERMIT
1 PHONE '
c NTeacro
NE / OUTLETS-SWITCHES-RECEP 10.00/1.00
/✓1'��J L uc.rvo. LIGHTING FIXTURES - 10.00/1.00
r.GNrRAcroR's APPLIANCES-RESIDENTIAL 4.00
i AooREss' �y '
I ,?Q GUP$-'�/pro.•// PHONE 16�_ / PANELS 10.00 PATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO,
OR PANELS (OVER 200 AMPI 20.00
ENGINEER -
LIC.NO - SIGNS TRANS. 3.00
ARCH.OR ADDRESS ErvG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ASDDRES MOTORS - SEE FEE SCH.
SERVICE CHANGE 20.00 fr x
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z,"' (commencing with Section 7000)of Division 3 of the Business and
y Q at BLDG. ELECT. PLG. MECH.
r w rofessions Code, A m se is in full ford nd ff ❑ ❑
oz m o LicensepC�as�s ,( Lic.Number V
ate ,VJ Contractor
IrkiZEk,¢ y s _ •BUIIDING;P8RM1T„; K I FVx
¢ ¢w u OWNER-BUILDER DECLARATION
W ;u y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD : .INFORMATION
FUOA - Law for the following reason. 7031.5,Businessland Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter, 10.00
cea 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.
d EO LL requires the applicant for such permit t0 file a signed Statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contr actor's License - _
rzi
Law(Chapter 9(e.mmencingwithSection 7000)ofDivision3of01e - - P��
E 4 o Business and he alleged
Code)or that he is exempt therefrom and QTY. , PLUMBING PERMIT = - ,FEE+
¢ Hct the basis for the n ora exemption.Any violation t tSection7031.5 ' STORIES ,.TVPE CONSTR.
a g � by any oretha five handle subjects the 0),): ant too civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.): '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP BEs.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 Ih ere on,and who does such work FIXTURES-PER TRAP 5.00 S 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mentsarenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that h - . . .
e did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB , Other
ti . INDUSTRIAL WASTE INTER. 30.00 11 F-1 . O El 1:1❑ I,as owner of Ole property,am exclusively contracting with
licensed contractors to construct Ole project(Sec. 7044,Business LAWN 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(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. f7 TRACT NO. PARCEL NO.
O Fam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VE(JT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACG DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING 'UIP." U Op 5.00
1 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 N0:
copy thereof(Sec.3800,Lab.C.) yM�� � Of ❑ ljokq
Policy No. Company
O ❑ Certified opy is hereby furnished.
Z ❑ Certif copy is filed, itp the inns Ivision, FIRE SPRINK ENERGY T-24
FO Applicant__ a�.a,.G-JPZ L5 MfSC.- REFER TO ORD. YE] N❑ Y [] N[3
Lid� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00/0- FLOOD ZONE A.L.U.G.
CL Q COMPENSATION INSURANCE PLG.CONTE, LIC.No, PLG, // ) O'V y N V N[](This section need.not be completed if the permit Is for one TOTAL oC
Z hundred dollars($10(Dor less.)
U O 1 certify that in the performance of the work for which this per. DTV: MECHANICAL PERMIT tFEE FWSUMMARY
LL F mit is issued,1 shall not employ any person in any mannerso as to
O W become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate ofF.x-
In F ? emplion,you should become subject to the Workers'Compensatin APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U, such provisions or this permit shell be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 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 _
Lender's Name - HEATI NG UN IT 100,000 B.T.U.)9.50 '
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information rdicsis state
I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING �� �'
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTUI 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
Agm of this permit MECH.CONT. LIG NO. MECH.
TOTAL - TOTAL"
are of App lea.1/C.al Date
OFFICE COPY