C 9516 :ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT N ONLY
JUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
DIAG -� APPLICATION & PERMIT
.ORES7�OZ � 9 516
A)BUILDING-ELECTRICAL-PLUMBING-MECHANICAL'
Ow.-. C/ - PLAN CHECK VALIDATION
.MAME GC� OTV. ELECTRIC PERMIT FEE
PHON�J// (J�V
CONTRACTORS � UTLETS-SWITCHES-RECEP 10.00/1.00
u c.No. LIGHTING FIXTURES 10.00/1.00
ADOREscroRs APPLIANCES-RESIDENTIAL 4.00
LJ/I �T PNONE f7//'77 PANELS 10.00 DATE OF APPLICATION
✓
ARCHITECT PLAN CHECK FEE P.C.NO.
DR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. - SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o D o LICENSED CON']RACTORS DECLARATION TEMP.POLE 30.0 1985
or u u I hereby affirm that I am licensed under provisions of'Chapter 9
2 wISSUANCE DATE
va a y (commencing with Section 7000)of Division 3 of the Business and ELECT. PLG. MECH.
r y z professions Code, 1 ry license is in full force it f V
2 o m - License Cl ss Lic.Number ❑ ,
9 y Date_ Contracto L El
IF w a OWNER-BUILDER DECLARATPOr BUILDING PERMIT
w °a ° MISC.- REFER TO ORD INFORMATION
; I- I hereby affirm that 1 am exempt from the Contractor's License '
VALUATION
u O¢ Law far the following reason.(Sec.7031.5,Business and Professions S/FT.
r - Any PERMIT ISSUANCE 10.00
f as Code: e,demysh wu nly pair any struturep prior
tlow island,.heq
QQa ° Impfov¢,d¢mOhih,Ofr¢pair any atrllCtnf¢,prlOr t0its 1SSilamee.a50 ELEQ CONTE. LIC.NO. ELEC.
T. °LL requires the applicant for such permit to file a signed statement that
TOTAL
n wlie is licensed pursuant to thu provisions of the Contractor's License �A�E PERMIT TO
rii Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe 7��IC•f,l��[���`�
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE „ -`
¢ I- thebasis for the alleged exemption.Anyviolition cfSection703i.S STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(SS00)J:
❑ 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 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 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.
'f• merits aro not intended or offered for sale If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of tileJ. INDUSTRIALWASTE INTER. .30.00 Q IND CON O Ot❑ner
❑ d as owner of the property,am exclusively contracting with
licensed contractors m construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codvproperty Contractor'sbuildLicense Law docs not apply
to tr owner of property who builds tr int rts)licensed
fuand who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclortsl licensed pursuant m
the Contractor's License Law, SEWER-SANITARY-STORM EA.200f[/10.00 TRACT NO, PARCEL NO.
❑ tum exempt under Sec. ,B.&p.C.for Ibis
rellsnlWATER HEATER W/VENT 6.00
l
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO. I
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 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 NO.
copy lhereof(S¢C.3800. .
Policy er Company,mny
O ❑ Certified copy is hereby ftyWished. FIRE SPRINK ENERGY T44
Z Z ❑ Certified copy is Nle��5{�rvith JJyllt ty inspection division.
� P- Applicunt� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CERTIFICATEOFEX TIONFROMWORKERS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
LU _ COMPENS IONINSURANCF 1 PLG.CONTE. LIC.NO. PLG,
CL o (This section need not be completed if the permit is for one TOTAL v❑ N❑ V [D N❑
0 Z hundred dollars(5100)or less,)
U 0 1 certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LLU mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
U a hale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING SO 0
} N
NOTICEtion,TO APPLICANT: If,after making this Certificate sa ion
F ? em vision you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions io the his pe Code, you most forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT TO 10J100CF.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 6.00 SEISMIC FEE /� S
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(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify tlmt I have read this application and slam 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(3 H.P.or 100,000 B.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.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue ago nsI TOTAL TOTAL i'7f d
'd City in Consequence of the
granting ofthisp it. MECH.CONT. LIC.NO. MECH.
Signa of Applic ontmctor Date
OFFICE COPY