8913 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - - _----PERMIT NUMBER a
B I1DING APPLICATION & PERMIT 4
aUOpF
at
e-V �fD BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 8913
OWNER'S - G1 PLAN CHECK VALIDATION
NAMES /1/' OTY. ELECTRIC PERMIT - FEE
STWC0-0 ✓V
J • PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
Zm )c- uO.No. LIGHTING FIXTURES10.00/1.00 - -
CONTRACTORS
aooR11Ess 1 1 q APPLIANCES-RESIDENTIAL 4.00
�Ol `LU S 5 PHON 'LZZ PANELS - 10.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.N0.
OR ^✓J, PANELS (OVER 200 AMP) 20.00 - ..
ENGINEER-}"D / uc.No :J G -J) 1[/
I - rt SIGNS TRANS. 3,00
ARCH.OR ENG, I PERMIT VALIDATION
ADDRESS 1�,1,1� SPECIAL CIRCUIT- 5,00 ,
2-Ok'��1�rx-r'ASISiflLjs� 410 arrEMP.METER OR POLE INS. 20.00
APPLI DDRESS rs MOTORS SEE FEE SCH.
' � RSERVICE CHANGE 20.00 ,-//K��, -
°¢ TEMP.POLE 30.00 ,/ .(� �//_
.02 LICENSEDI CONTRACTORS DECLARATION T .��S/a)<'
Dot.v I hereby affirm that I am licenwd under provisions of Chapter 9 - ISSU CE DATE
,Ha <w (commencing with Section 7000)of Division 3 of the��Business and
H N i Professions Code W my license is in full ro ' O+t BLDG. ELECT. PLG.
MECH.
a z m ° Licensy Cl asv Lic.Number ILT
Dam �Gj Contracmr
Qyf
E ¢ w < OWNER-BUILDER DECLARATION BUILDING PERMIT
. MISC.- REFER TO ORD INFORMATION
X 3 u N. 1 hereby affirm that I am exempt from Lite Contractor's License �k .�yIgTION $/FT.
'H ¢ 04 Law for life following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 10.00 P��V
3 ">f Code:Anycityorcounty which requires a permit to construct,after, a--�0
¢ CC Q ° approve,demolish,or repair any structure,prior t0 its Issunllcc�al'o ELEC.CONTR. LIC.NO. ELEC.
°LL requires the applicant for such permit to file a signed statement that - TOTAL
n w m he is licensed pursuant tothe provisions of the Contractor's License p 1 IJ 'PERMITTO
Law(Chupter9(commencingwith SectIoR7ODo)of Divlslon3ofthe 1�'/A 1M
i i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE E d L s LL
¢ t- $. IhC haeie for the alleged exemption.Any violet ion n(Sectimh 703 LS - ST�Rs� TYPE CONSTR.
by any applicant for a permit subjects the applicant Ron civil penalty Y 0I VUMV
of not more than five hundred dollars($Soo).): 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 Dec.GROUP RES.UNITS
their 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,CON D. 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 F IXTUR ES-PER TRAP 5,00 SO.FT.FLOOfl AREq TOTAL ACREAGE
• himself re of rote his own employees,provided that such Improve-building
ments improvement
or within
onefor
year
If,however,the theo owner, GAS-EA.SYSTEM-1INC.4OUTLETS 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 Salo.). RES IND - CON PB Omer
1,
❑ I,as owner of the properly,am exclusively cont0 Elracting with INDUSTRIAL WASTEINTER. ' � 30.00 El 0. El
licensed contractors to 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(EA.)' 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200f1/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Seca ,B.&P.C.for this WATER HEATER W/VENT • 6.00
reason
'Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO. '
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm For 1 have a Certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified a ZONING ENG.SITE NO.
copy Ibereof(Sce.3800,Lab C.f�.
Policy No. Con.pan.Sl��_ .
O ❑ Certified co y is hereby f nished' FIRE SPRINK ENERGY T44
Z Z ' NI Certif is f fill the City inspection division. MISC.- REFER TO ORD.
O APP'cun[ y ❑# NF -y'[D NC]
N CERTIFICATE OF:EXIiMP N PROM WORKIiRS, PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCEPLG.CONTR. LIC.NO. PLG.
CL 0 ffhis section need not be completed if the permit is for one TOTAL V'O`1v?IN V N�
:3 Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the'work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U- H mit is issued,I slmll not employ any person in any manner so as to
O W become subject to the Workers'Compensation Lows of California.
y Dfat. - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 3 tl $ z
}'to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F� Z emption,you should become subject to the Workeri Compensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cod., you must forthwith comply,with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY . AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby of inn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this pencil is issued(Sec.' MICROFILM
3097,Civ.C.). . 1 HEATING UNIT(TO 100',000 B.T.U.) 8.00
lender's Name �fD�,1� HEATING UNIT(O VER100,000B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
'• information is correct.1 agree to comply with all city and county PLUMBING '
Ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER=COMP m (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly far 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 - PERMIT ISSUANCE, 10.00 CONST.TAX
muy in any way accrue Wifinst said City in consequence of the
grand O permi MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant Comructor Date -
OFFICE COPY