8973 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
'"LoINc APPLICATION & PERMIT
REss 8973
Aoo
.LO p BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME,/ OTY. ELECTRIC PERMIT FEE
�l PH ,E KJJ D
NAMERACTaRs Al J C O.No. UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS APPLIANCES-RESIDENTIAL 4.00
CONTRAC
9J• seIV PHONE Z53PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
SIGNS TRANS. 3.00
ARONF"EOR ENG" / SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
G/iFL•/ f1b ZIP rrEMP.METER OR POLE INS. 20.00 _ J
APPLICANTS MOTORS SEE FEE SCH.ADDRESS
y03ill SERVICE CHANGE 20.00
w, oo LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30,00
st u. I hereby affirm Ilett I am licensed ursder provisions of Chapter 9 ISSUANCE DATE
w a H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions s unJ y license is in lull Number ❑ ❑ ❑
z o m — License Class�- Lic, tu111
o� ' O Dater �}Q= Contractor
a m s ✓ BUILDING PERMIT
a o d
OWNER-BUILDER DECLARATION INFORMATION
X ; u m I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
F .. H¢ Law for the following reason.(Sec.7031.5,Busi momid ProfessionsPERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any City or county which requires a permit to construct,alter,
Q � �' ELEC.CONTR. LIC.NO.
rt ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.
n Dis LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E:
he is licensed parsuunl to the provisions of the Contractor's License /
HZi
Law(Chapter 9(Commencing with Section 7000)of Division 3 oftlic
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M t-m 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 civil penalty
of not more than five hundred dollars($500)J: ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as ' BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
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 Low does not apply to an owner of
property who builds or improves thereon,and who docs Such work F IXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such int building
hiepts mself a act through his or offered employees,
or provided that S,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
Ior improvement is sold within one year of completion,the name
r-
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractors License Law Anes 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 contractors)licensed pursuant to Z SEWER-SANITARY-STORM EA.200f[/10.00 'Zp
the Contractors License Law. aCC TRACT NO. PARCEL N0.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER WOVEN T 6.00
reason
Owner Date WATER SYSTEM ' - 5.00 ACC.DATE ACC.FILE NO,
WORK E RS'COMPF-NSATION DECLARATION WATER TREATINGEQU -C,5,00 -
I hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Sec.3600,Lab C.).�r S
Policy No. Company r�—ARL ry S(
—_
0 ❑ Certlliedcopyi,I furnished ( FIRE SPRINK ENERGY T 24
Z Z ❑ Certifi p Be with the city inspection division. MISC.- REFER TO ORD.
0 Appncam Y ❑ N❑ Y ❑ N❑
CC In CE R'l'I FICATE 0 EXIT PTION FROM WORKERS' PERMIT ISSUANCE 10.00 l0 01�_ FLOOD ZONE A.L.u.C.
LU > COAIPF;NSATION INSURANCE . PLG.CONTR. LOC.NO. PLG. g
CL a (This section need not be completed if the permit Is to,one TOTAL 30 Y❑ N❑ Y C] N❑
hundred dollars($100)or less.)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued/'I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
y Dare Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ W NOTICE TO APPLICANT: if,after making this Certificate of lie'
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
V such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency far EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
HEATING UNIT(OVER 100,000 B.T.U.)9.50
- Lender's Names ELECTRIC
I certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING J
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 � .i
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property representatives
of this
purposes.
(Wo) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
may in any we y against said City in consequence of the
gra golf rmit MECH.CONT. LIC.NO. MECH.
4ur O TOTAL TOTAL
Signal of Appli am/ ratter Date
OFFICE COPY