9501 / AFPCICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Burl-DING PROJECT I DENTI FICATI ON PERMIT NUMBER
-BUILDING APPLICATION & PERMIT
ADDRE
t
DING - ELECTRICAL-PLUMBING
-MECHANICAL 950
OWNERS PLAN CHECK VALIDATION
NAME
• / A_er v Y ELECTRIC PERMIT FEE
L./f F / PHONENAAMIERACTORs / UTLETS-SWITCHES-RECEP 10.00/1.00 Lf
J94 i c0aIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
D'IREs� `��^j( o � L�0 APPLIANCES-RESIDENTIAL 4.00
oHI E T /✓/ O` �pHONE2))-033 PAN ELS 10 DATE OF APPLICATION
OORRCHtTECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AR H.
ENG, SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S
AooREss MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 _
wo O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 p p/,& y
a u 1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
NZ ,vAi (commencing with Section 7000)of Division 3 of the BusiOesi ynd BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full f c�e��'Ipy�dee,if,�pp /// ❑ ❑ ❑
Z i m - License Class Lie.Nun.he /U�f'I,PJ 8
4 H w Uate 0_ W 0-7 Contractor AUG
((.� I (� ryry
u. a w a 1 OWNER-BUILDER DECLARATION 6 A V ee + " 19t7F BUILDING PERMIT
U MISC.- REFER TO ORD INFORMATION
w ;' m I hereby a(fnn that I am exempt from the Contractor's License
HLLoj Law for the following reason.(Set.703 I.S.Businessand Professions PERMIT ISSUANCE VALUATION SIFT.
mj Code:Any city or county which requiresa permit to Construcl•alter, I Q
Qec Q improve,de1nOI1S11,Or Apar!any StftlClure,prior to its issuan Ce,also ELEC.CONTR.• LIG NO, n'
ELEC. �Q pec
i w m u requires the applicant for such permit 10 file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractors License
r z a
Law(Chapter 9(commencing with Section 70000of Division 3 of the
x o Business and Professions Code)or that he is exempt therefrom andGTV. PLUMBING PERMIT FEE LG
¢ r m lie basis for the alleged exemption.Any violation Of Section 7031.$ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(SS00)J: ALTER-DRAIN -WATER (EA.) 5.00
❑ 1,as owner of Om property,or my employees with wages as BACK FLOW PROTECTDEVICE 400
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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00• 50.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered forsale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement 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 for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
❑ I,as owner of the property,am exclusively contracting with F-1 El ED ❑
licensed contractor, to construct the project(Seo.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts]or such projects will,a contraclor(s)licensed pursuant to
Ute Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO.
❑ lain exempt under Sec. ,B.&1'.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.OATE ACC.FILE NO.
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofectolenl to'elf-mon".
or a certificate of Workers'CompensaI I yr �a certified ZONING ENG.SITE NO.
copy the�co�1S �/ NT
Policy Nlyl=. `fi�. ny
O ❑ Certified cols her by l' rnisly nJ /V I FIRE SPRINK ENERGY R24
�Z� ❑ Certified �y 'h_.filcd iUylh cit inspec l ion division.
F npplicum MISC.- REFER TO ORD. Y [] N� Y ❑ N�
CER IIICn'PEUPb IiMPI'101 FRO, WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.Lu.c.
W COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not be completed it the permit is for one TOTAL Y❑ N� Y [:] N
U O hundred dollars(S 100)or less.)
I is certify that h the performance of the work for which this per- GTV MECHANICAL PERMIT FEE FEE SUMMARY
CU mit is issued,1 shall not rkers'y any maOm in any ma nneror is to
Q m become subject to the Workers'Compensation Laws of California.
y
Date-Applicant ALTER OR ADD TO MECH. BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- 5.00
I'- Z emplion,you should become subject to the Workeri Compensation APPLIANCE5.00 PLAN CHECK
provisions of lire Labor Code, you most forthwith comply with
C) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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.
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC O
ordinances an
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information correct I agree to comply with all city and county d state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
Ione- amhori<n ropertyf for
of this city to enter upon the BOILER-COMP
above-mentioned property for inspection purposes. (Ove.100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino grind liabilities,judgments, costs and expenses which
May i y way accone nst�said'C7 y t nsoquence of the PERMIT ISSUANCE 10.00 CONST.TAX
Banti if this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si of Airpli any ontra Date
OFFICE COPY