9483 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATIONk PERMIT NUMBER
BUILDING APPLICATION & PERF 9483
ADD ass
' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL '
PLAN CHECK VALIDATION
NA OTY. ELECTRIC PERMIT FEE
PHONE
NGN ERAcrDRs OUTLETS-SWITCHES-RECEP 10.00/1.00
FME
rvOp[ LIGHTING FIXTURES 10.00/1.00
WNrancTOa'S APPLIANCES-RESIDENTIAL 4.00
' uwirl PHONE O(JJ V{C/ PANELS - 10.00 DATE OF APPLICATION
RCHREcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO ISIGNS TRANS. 3,00
ADD ESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID
APPLICANT'S I
ADDRESS MOTORS SEE FEE SCH. .AUG gegE
i' SERVICE CHANGE 20.00 117BD
o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 //�����{L�Qy� �pj� p pg�lOU
< in U I hereby affirm that I am licensed under provisions of Chapter 9 MSVANCECDuTE
y <H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. ME
R C Z ProfessionsC S and 1'cense is in full for d IT ct ❑ ❑ ❑
oz m 0 License a s Lic.Number E
,n r Date Contractor
stm'A BUILDING PERMIT
¢ Sc w OWNER-BUILDER DECLARATION INFORMATION
w ;LL m 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION S/FT.
tLLw J Law for the following reason,(Sec.7WL5,ermit tocand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires e permit toconstruct,alter,
Se Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.DDNTR, LIG NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL
a w m w he is licensed pursuant to the provisions of the Contractors License PER
TO
r Z a Law.(Chapter 9(commencing with Section 7000)of Division 3 of the
i G Business and Professions Code)or that be is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
y ; by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($5010).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,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,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 9G.FT,FLOOR AREA TOTAL ACREAGE
himself or through his awn employees Provided that such improve-
orimprovemements an notnntended or within offered year
ILhowetinthe the owner-
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or lder will hav 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 he did not build or im- BUILDING USE
prove of sale.)' INDUSTRIAL WASTE INTER. 30.00 B I❑ ❑N PB El 1:1 1,as o
❑ Las ownernee purpose contracting the properly,am exclusively cocling with
licensed contractors to construct the 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 contructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO,
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6,00
e�son
Owner Date WATER SYSTEM 5,00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby ate of that I have a certificate In consent or sell-insure.
ora certificate affirm
Workers'Compensation Insurance,to a self-insure.
certified ZONING ENG.SITE NO.
copy the'0,1aec.3800,Lab.CJ. n"v 1 I� k
Policy No. Company (lW T
❑ Cert is hereby furnished.
Z Z ❑ Certifie Ili Ti1(�;'„I it1 t e T/ inspection division. FIRE SPRINK ENERGY TQ9
f- O Applicant U MISC.- REFER TO ORD. Y ❑ N❑ Y❑ No
� y CERTIFICATF-OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL Z( This section need notbe completed if the permit is for one TOTAL Y❑ N❑ Y C-] N❑
hundred dollars($100)or less.)
V O I certify that in the performance of the work for which this per. OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner So as to
U become subject to the Workers'Compensation Laws of Calilornia.
y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAQOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00the
3097 eCiv.C.j"ce of the work for which this permit is issued ISec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lenders Name H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state 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.GO 00,000 B.T.U.) 6.00 PLUMBING
vedinume.formatio and state laws relating etc to building construction, and
hereby authorize representatives of this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property representatives
i 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 ORD CONST.TAX
may any way accrue against Said City in consequen�fff of the10.00
gmni gOft�sPe i /�// / � MECH.CONT. LIC.NO. MECH.
LU+ / O
% J TOTAL
&g
nature of Pphcant It a for Date �'(G
OFFICE COPY '