09704 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BU 14DING PROJECT I DENT[FICN \yr
nooREss PERMIT NUMBER
BDILDING . APPLICATION & PE`s IT
STEBUILDING
` 09704
9
.�q
7/LVE [rCslC BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNER'a - PLAN CHECK VALIDATION '
OTV• ELECTRIC PERMIT FEE
CONi� NT NE
NAME CTOR'S
.�. rvnmE OUTLETS-SWITCHES-RECEP 10.00/1.00
L-is LIGHTING FIXTURES 10.0011.00
CONTADDRESS TO .s p " - APPLIANCES-RESIDENTIAL' - 4.00
04Mp� PRONE �/� PANELS 110,00 DATE OF APPLICATION
!APT ECT -
OR � PANELS (OVER 200 AMP) � •20.00 PLAN CHECK FEE P.0-NO
.
ENGINEER
' uc.NO. SIGNS TRANS.. 3.00
ARC".08ADDRESS ERG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE - - 20.00 �/ G
Foo LICENSED CON'T'RACTORS DECLARATIONDECLARATIONTEMP.POLE 30.00
<u u �I hereby uflinm that I am licensed under provisions of Chapter 9
F 2 u ISSUANCE DATE
b¢ m (Commencing with Section 70se i of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Pml'essions Co, auJ license is in full lure t - ❑ ❑ ❑ r�
oI'm o License /pass Z Lic.Number I/N I'
H w Date Contractor_ 2Q
F � - J'
¢ m Si J BUILDING PERMIT
¢ a w ¢' OWNER-BUILDER DECLARATION - «
A o D INFORMATION
w ;A m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD -
u0¢ Law for the l'ollowin reason, 7031.5,Business Professions VALUATION $/FT.
- J g PERMIT ISSUANCE 10.00
m0 Code:Any city orcounty which requires a permit to construct,alter,
ce ¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also L .CONTR. - LIC.NO. ELEC.
'm" requires the dp u applicant for SUCK permit LO file a signed statement Li use TOTAL PER T TO
u K he is licensed pursuant to the provisions of the Contractor s License
r z ¢ Law(Chapter
' (Cha (commencing with Section o
Business and Profession, ode)or that he is exempt Division
and ,E
CITY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. 3 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 -
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
no
their sale compensation,will do the work,and the structure is t OCC.GROUP RES.UNITS
intended or offered for sale (Sec.7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND.'5,00
Code:The Contractor's License Law does not apply to an owner of _
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP S,OO 50.FT.FLOOR AREA TOTAL ACREAGE
A* himself re through his own employees,provided that such improve-
or improvement
not intended within
onefor
year
If,mpletion thebuildingwilding GAS-EA.SV$TEM-1 1NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving That he did not huild or int. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove forof sole.). INDUSTRIAL WASTE INTER3000 ' RES IND CON PB Dinar
as owner m
❑ I,
as owner of the properly,aexclusively contracting . .
ucting with 11 ❑ ❑ 1:1 Cl
licensed Contractors to construct the project(Sec.,7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASS S
ruSOR$PARCELNO. -
and Professions Codi:The Contractor's Licente Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such Prowls with it contradons)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
ElI am exempt under Ser..,B.&P,C.for this' WATER HEATER W/VENT 6.00
Ow
reason
ner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORKERS'COMPENSA1 ION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent Io ser-insure, -
or a Certificate of Workers'Corm
creation Insurance,or a certified ZONING ENG.SITE N0.
'copy thereof(Sec.3g00,Lab.C.)./ -
Policy No. Company r �N4ie"�4
O ❑ 'Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Elf
Certlfle s y is tiled w'
the city inspection division.
Applicant MISC.- REFER TO ORD. V N�' v N�
�+ PERMIT ISSUANCE 10.00
- CER FICA .O °%IiMPI'10 UM WORKERS' FLOOD ZONE A.L.U.C.
LU COMPENSATION IN.URANCE PLG.CONTR. LIC.N0. PLG, t,
d O (This section need not be completed if the permit is•for one TOTAL V❑ N� Y ❑ N�
2 hundred dollars(S 100)or less.)' -
U O ['certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mil is issued,1 shall not employ any person in any Insurer so as to
O W become subject to the Workers Compensation Laws of California. -
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICIi TO APPLICANT: If,after making this Certificate of Ex. -
F.. Z rotation,you should become subject to the Workers'Compenwtimt APPLIANCE 0 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions m this Permit shall be deemed revoked. AIR HANDLING UNIT(T ,Z)0
CONSTRl1CTION LENDING AGENCY AIR HANDLING UNIT(OVE 0 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WIT ) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ce.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address - HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above 2 VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city zinc[county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise s representativveec this BOILERCOMP- (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly tar inspection of city to enter upon the
hipurposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and"expenses which pERMITJSSUANCE 10.00 _ CONST.TAX
may in any way accrue against said City in consequence of the
gfa of this pc 'L MECH.CONT. .- LIC.N0. MECH.
TOTAL TOTAL
�C. arc pp[cant/Contact Datc
OFFICE COPY