09775 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL'6
BU LDING PROJECT I DENTI FICATI ON ERMIT NUMBER
BUILDING APPLICATION & PERMIT
A0DR Ess /n1 � �, /�
3 B-2- Sl-�TPAALl6 � JBUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09775
OWNER'S
NAME QQ ^ I ,,AO PLAN CHECK VALIDATION
•� F-�+ P 252 TV. ELECTRIC PERMIT FEE
P ONE
CONTRA TORSNAME f1,, UTLETS-SWITCHES,RECEP 10.00/1.00
Co�r+�uC NO rc3T38LIGHTING FIXTURES 10.00/1.00
nooesss T/O1RS �/ \ '/ /�� APPLIANCES-RESIDENTIAL 4.00
3o I V,"L- V�-Y PHONE 72S-/2bl PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC
ADDRESS ENG. SPECIAL CIRCUIT $,QO PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESSTs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 y
w o o LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00 )Olds'
w
< u I hereby of f inn that I um licensed under provisions of Chapter 9
:2 IS DANCE DATE
v, a `w (commencing with Section 70001 of Division 3 of the Business and
H H Z Professions Code,arW my license is in full fore an f' BLDG. ELECT. PLG. MECH.
Z O w- License Chess Lie.Number Y
Q o- a Date={-/� Contractor
Q y I
¢ ¢ w a OWNER-BUILDER DECLARATION BUILDING PE IT
X
;LL w 1 hereby affirm that I am exempt from the Contractor's License M'SC.- REFER TO ORD INFORMATION
.. o J Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.
- PERMIT ISSUANCE 10.00
rot- Code!
e,demysh countywhiny structured prior
ionto issuance,also
a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UC.NO. ELEC.
ar
is O ¢ requires the applicant for such permit to file a signed Statement that TOTAL
E
m o he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z Q
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
4 O Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5
i g§ by any applicant for a permit subjects the applicant to civil penalty STORIES TYPE CONSTq.
of not more than live hundred dollars($500).): 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. 7144, 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 50.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement willh v is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.1 2.00
Provbuilder will have the burden oCpmving that he did not build of int- BUILDING USE
Prove 1,as ownerose
of sale.). INDUSTRIAL WASTE INTER. 30.00 RES Irvo CON PB Other
❑ L as owner of the properly,he exclusively contracting with � Q El 0
licensed contractors m 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 .00
contracts for such projects with a contmetc rls)licensed pursuant to
the Contractor's License Law. SEW ER-SAN'TAR V-STORM EA.200tt/10.00
Q TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,B1P.C.for this WgTER HEATER W/VENT
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
N'ORKIiRS'COh1PIiNSAT10N DECLARATION WATER TREATING EQUIP.Cib, CII
I hereby affirm [hat I have a certificate ofconsent inscirinsure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy themof(Ses,3800,Lab.C.).
Policy No. Company J� �•a]✓ I+ i4•^^ a' •,
0 ❑ Certified copy is hereby furniFhud. ll
Z Z O Certified is f-Iyd with the city inspection division. s FIRE SPRINK ENERGY T-]4
AVP[icant_ (f1/_MPT MISC.- RE ER TO OR . Y NF Y [] NE]
~ ON - (1 PERMIT ISSUANCE
LU - CERTIFICATE E EXEMPT T ON FROM WORKERS' 10.00
W COMPENSATION INSURANCE PLG.CONTR. FLOOD ZONE A.L.u.c.
LIC.NO. PLG.
Z (This dollars need not be completed if the permit is for one TOTAL V N� V rv�
UO hundred 1ccldollar IS 100)Dor eless.l
I certify that h the to employ
of the work for which this per.gQTY. FEE SUMMARY
LL U mit is issued,I shall not employ ung person in any manner so as toMECHANICAL PERMIT FEEObecome subject to the Workers'Compensation Laws ofCulilornia.
Daze ICAN : I TER OR ADD TO MECH. BUILDINGZ NOTICE TO APPLICANT: IC after making this Certificate sa ion 5.00? emvisionon,yof ou the L bor me Code you tmust workers'CompensationLIANCE5.00 PLAN CHECKsuch provisions for thisbperniitts1iall bed med revokdwith comply wuh HANDLING UNIT(TO 10 FEE,000GF.MU 4.00CONSTRUCTION LENDING AGENCY HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm maz 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.
3097,C'v.C.). HEATING UNIT(TO 100,00 B.T-U.1 9.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify lhall have read this application and stole lhxl Om above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP H.P.Or 100,000 B.T.U.) 6.00 Q
hereby nuthoriee representatives of this city to enter upon the
above-mentioned Property for inspection purposes. BOILER-COMP Over
100,000 BTUIs
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
may in any way accrue gains said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
granlin t�/5�ermlL p MECH.CONT. LIC.NO. MECH.
Q-�,� 0 J' TOTAL
Signature of Applicant/Contractor Date TOTAL
OFFICE COPY