9303 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[FICATI ON PERMITNUMBER
�( SDILDING . APPLICATION & PERMIT O�
ADOREy5O 999 s'rLVC-Aa Cr, BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER•a PLAN CHECK VALIDATION
NAME
. SaEu p4L [O, QTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
I NAE _ p `` UTLETS-SWITCHES-RECEP 10.00/1.00
L �LL'2'Te uta NORq9/'b77 LIGHTING FIXTURES 10.00/1.00
ADN HESS R's y APPLIANCES-RESIDENTIAL 4.00
/
AD HESS Gt LC.a I (Y'
J�IOO C EV-40L AV PH P 2`1'7 71I/ PANELS 10.00
DATE OF APPLICATION
OR
RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00'
ARCH,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 /f
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS
SERVICE CHANGE 20.00 .�I(o%-j
o 0 o LIC17NSED CONTRACTORS DECLARATION TEMP.POLE rA,D 30.00
ri w 1 hereby affirm that I um licensed under provisions of Cheplcr 9 GLOGbTLr CEO'I✓Ib DI'T.{ r�T'S ISSUANCE DATE
< e (commencing with Section 7000)of Division 3 of the Business anJ 'I) I` � - BLDG. ELECT. PLG. MECH.
Professions Code, ad my license is in full for ahe(GC�' LD X50 S K ' t�V'
H. ,'$ License Class �[[`Lic.Number 77 XX U �y
w °w Dme�/6 .,JS= Contract..._!LL {� A.oe-Arj cpV - ❑ LYl ❑ ❑
s CU BUILDING PERMIT,
a x: ¢ ¢ OWNER-BUILDER DECLARATION el'11n0
s o a INFORMATION.
xu ; N I hereby affirms that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o j Law far the followin reason(Sec.7031.5,BuRnessand Professions a0�0 VALUATION E/FT.
_ g PERMIT ISSUANCE _
m; Code:An y ci l y or con n ty wit ich req u i res a perm i l i o co nslTme t,alICT,
le aa 4 0 improve,demolish,or repair any strucpne,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 0¢ requires the applicant for such permit to file a signed statement that TOTAL /�--�-
w m p he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i 4 Qo tlusities,and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Tae basis for the alleged exemption.Any violation ot'Section7031.5 STORIES TYPE CONSTR.
Le by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 6.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended 0r 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,sale,
provided that such improve,
mesilate throughh isot oroffered emploee sa provided
thathowevsuch
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
budder will have the burden of proving that he did not build or im- - . - . .
BUILDING USE
prove for purpose of sale.). RES IND CON PB Ouher
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B.' 6.00 ASSESSORS PARCEL NO.
13
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(EA.) 1.00
contracts for such projects with a contrachms)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
0 Iumexemptunder See ,B,&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK 6RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certifiedZONING ENG,SITE NO.
7t, copy thereof(Sec.3800,Lnb.C.l.
Policy No. Company WD Drf.QJA4- 140 0 ?y
O ❑ Certified co y is hereby Fu shed 7646/0.7 FIRE SPRINK ENERGY T-24
Z`g� ❑ Certified say is Bled with tpI, n inspection division.
(\ Applicant •�1 .1 MISC.- REFER TO ORD. Y 0 No Y ❑ N[]
~ yPERMIT ISSUANCE 10.00
LU - CE T KATE EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W 1 COMPEE INSATIOJO N INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ NE] Y EJ No
hundred dollars 11100)orless I
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY, '
LL 1- mil is issued.I shall not employ any person in any manner so os to
O W become subject to the Workers'Compensation Laws of California.
a Data Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of fix
F 2 caption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1
Sochi provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 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. MICROFILM
3097,Civ.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 Address ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
udonances n correct I agree to comply with all oily and county BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate . I a relating to building construction, and
hereby authorize rePresentltives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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 CONST.TAX
may in a way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
granting this permit MECH.CONT. LIC.NO. MECH.
7 1G j TOTAL TOTAL
S' ore of Applicant/Contractor Data
' OFFICE COPY ,