09757APPLICANT TO FILL IN INFMMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIN ON
APPLICATION &P IT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
.0.9757
BUIeDING,
ADDRESS
2D33v ✓E�u'S EK
,OWNER'S
.A 'Wel-)
/�(J/ E� i el- J PHONE
.. y
DTV.. # ELECT RIC PERMIT t ,FEE4
PLAN CHECK VALIDATION
-
-
DATE OF APPLICATION
CONTRACTORS
✓0 CCL&__-
.
-RECEP 10.00/1,00
LIGHTING FIXTURES 10.00/1.00
r'S
?flE, AssC
//. PHONE 9y/J0O
'OUTLETS:SWITCHES
APPLIANCES - RESIDENTIAL 4.00
PANELS " 10.00
OgcHi7ei -
ENGINEER _
' LID. ND.
PANELS (OVER 200 AM PI 20.00
PLAN CHECK FEE P.C. No.
-.
SIGNS TRANS. 3.00
ADDRESS ARCH. OR ENG. -
zm
SPECIAL CIRCUIT 5.0Q
PERMIT VALIDATION
n
ISSUANCE GATE ddd
BLDG. ELECT. PLG. MECH.
EMP. METER OR PO ; 20.00
APPLICANT s
MOTORS SEE FEE SCH.
SERVICE CHAN Q r. G, - 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod attd license Ism full fore eq�r
License a _ l- " Lia Numbed�_
Date contract.rt
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contiaemr's •License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
.improve, demolish, or repair any structure, prior t0 its issuance, also
requires the applicant for such permit Go file o signed statement that
he is licensed pursuant to the provisions of the Contractor
Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that his exempt therefrom and
IIIc basis for the alleged exemption. Any violation of Section 70315
by any applicant fire permit subjectsthelicanl loacivil penalty
of no[ more than five hundred dollars ($5$5000).0).);
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the shuctum is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such Improve-
mentsarenotintended or offered for sale. If, however, the building
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-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
controctors to construct the project (Sec. 7044, Business
and Professions Cade: The Contractors License Law does not apply
to an owner or property who builds or improves thereon, and who
contracts for such projects with a contractOGS) licensed pursuant to
the Contractor's License Law. -
❑ l am exempt under Sec. ,B.&FC. for thus
reason
TEMP. POLE 30.00
t ertinG
J ,
�d
I " 3 BUILDING PERMITv�'�+6;�
. INFORMATIONo" " e"
MISC. - REFER TO ORD
PERMIT ISSUANCEVALUATION
10.00
ELEC. CONTE, LIC. NO,
ELEC. /�/ bb
TOTAL /V
PERMIT TO
Ge
CITY, PLUMBINPERMIT a iFEE
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
'
RES -UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
- GAS - EA. SYSTEM -1INC. 4 OUTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - OVER 4 (EA.) .2.00
BUILDING USE
RES IND. -CON PS Omer
El 11 E] ❑ 1:1licensed
.
INDUSTRIAL WASTE INTER30.00
LAWN SPRINKLERS- 1 INC 5 00
V.B. . .
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEWER -SANITARY -STORM EA. 200ft/10.00
iRACTNO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WORKF-RS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate ofcmtsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a Certified
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified co hereby fur iyled.
❑ Cerif cor s fel f le inspen•.tion division.
Apphcnn
CERTIFICATED EXEMPTI
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
hundred dollars IS 100) or less)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person idany mannersoasto
become subject to the Workers' Compensation Lows of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the'perforenance of the work for which this permit is issued (Sec,
3097, CN.C.).
Lender's Name
WATER SYSTEM 5.00
ACC. DATE
ACG FILE No.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
FIRE SPRINK
v ❑ N ❑
ENERGY T2A
v ❑ N❑
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10,00
FLOOD ZONE
v ❑ N ❑
A.L.U.C.
v ❑ IN❑
PLG. CONTE. LIC. NO.
PLG.
TOTAL
CITY. 'MECHANICAL PERMIT FEE
- -
- s
FEE°SUMMARY' '
BUILDING
ALTER OR ADD TO MECH. 5.00
_
APPLIANCE 5.00
PLAN CHECK- FEE
_
AIR HANDLING UNIT (TO 10=17 -RIA) 4.00
- AIR HANDLING UNIT (OVER IOAODC.FM.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Address
I certify that I have read this application and state that the above
information correct. I agree twith all city and county
ordinances and state laws relatinging to to building construction, and
hereby authorize representatives this
is city to elver upon IIIc
above-mentioned property for inspection
h purposes.
(We) agree to save, indemnify and keep harmless'the City of
Cupertl ainst liabilities, m osts and expenses which
m in any ay accru sin i in consequence the
HEATING UNIT (OVER 100,000 B.T.U.19.50
ELECTRIC
O -/Cr`-
It!- _
VENTILATION FAN (SINGLE) 4.00
PLUMBING
- BOILER-.COMP(3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,0008TU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX `
MEL CONT. LIC. N0.
'
MECH.
TOTAL
w
TOTAL
are o `Appli ant/Contractor - Date
-r .. OFFICE COPY