9096 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES ONLY
BU I LDING PROJECT I DENT[FICATI ON PERMITNUMBER
BUILDING APPLICATIO O ^
y
ADDRESS QUILDING - ELECTRICAL-PL KCAL
(�
F[
OWNER'S H • �j PLAN CHECK VALIDATION
NAME /nJb- 09I�} OT YI ELECTRICPERMIT •FEE e
S - =k R ..
CONTRACTOR'S l I OUTLETS-SWITCHES-RECEP 10.00/1.00 '
NAME Is 1 ,097
:rvo. LIGHTING FIXTURES 10.00/1.00
AONTRACTORS K PPLIANCES-RESIDENTIAL 4.00
ADORES5 S' RN•TVJL, rill .g3f;kl.) -
- .C� 110NE _ PANELS .10.00 - DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
uc.No. SIGNS TRANS. 3.00 '
ARCH.OR ENG. - - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
' ZIP EMP.METER OR POLE INS. 20.00 "
APPLICANT'S IMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 0 o LICF-USED CONTRACTORS DECLARA'iION TEMP.POLE 30.00 slly/no
/
¢a,; I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE GATE
v, O1 (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Ni Professions Cole and m license is in full f0 a an ff - ? ❑ - ❑ ❑
z o w - License CI ss Lie.Number
E H w Date--'Contractor
;:w BUILDINGIF 'r.a;.�
¢ ¢w u OWNER-BUILDER DECLARATION ' ANF,ORMATION#,t a,
Pso u w I hereby affirm that 1 am exempt from the Contractor's License' MISC.- flEFER�
,u S a y p EVALUATION $/FT.
- 0
j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, '
¢ -¢ Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. /L Q ,OQ PERMIT TO
,
D ¢ requires the applicant for such permit to file a signed statement that TOTAL J
a
w u he is licensed pursuant to the provisions of the Contractor's License _ T -
rz > La..(Chapter 9(commencing with Section 70000ot'Division 3 art
a Business and Professions Code)or that he is exempt therefrom and OTV. - - PLUMBING PERMIT. FEE,
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN IEA.) 5,00 '
of not more than five hundred dollars($500L):
❑ 1,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 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 docs 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 int prove-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EA.SYSTEM OVER 4 IEA) 200
builder will have the burden of proving that h - - . .
e did not build or int- BUILDING USE
RES IND CON PB Other
prove for purpose of the
. INDUSTRIAL WASTE INTER. 30.00
❑ L as owner of the property,he exclusively ,7044,Bu with ❑ ❑ ❑ ❑ "
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts Or Contractor's
License
projects with a contrackhrts)licensed pursuant t0 SEWER-SAN EA.200ft/10.00
the Contractor's License Law. TRACT / P C NO.
Cl I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT - 6.00
reason
Owner Date WATER SYSTEM 5.00
E C ICE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent m sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified G ENG. TE NO.
copy thereof(Sec.3800,Lab.C.).
Policy NO. Company
0 ❑ Certified copy is hereby furnished. FI PRINKERGV T44
Z Z ❑ Certified copy is filed with the city inspection division. MISC. REFER TO OR
O Applicant V❑ N Y ❑ N❑
.CC to CERTIFICATE 01'EXEMPTION FROM WORKERS' - PERMIT ISSUANCE 10.00 FLOOD ZONE I A.L.U.C.'
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
CCL 0 (This section need not be completed if the permit Is for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z Imndred donors(S 100)Or less.) - -
U O 1 certify that in the perl'Ormance of the work I'or which this per. CITY. `- - MECHANICAL PERMIT` = FEE ' ' " FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to - -
O w beconic sup t to the Work ersf)O ensa n u vs of California.
a Date�a-Applicant aS.i1 ALTER OR ADD TO MECH. 5.00 BUILDING
} to IC i APPLICANT. If,after making thi ertificate of fix- '
? emption,you should become subject to the Work s'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 10MCF.M.) 6.00 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,(.'IV.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT 100,000 B.T.U.)9.50 6O
Lender's Address ELECTRIC
1 certify that I 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
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or1OO,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- .REFERYO 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
grantof thCH.
is ME
ermii. MECH.CONT. LIC.NO.
ME TOTAL
Signature o plicant/Contra t r Date
OFFICE-COPY