09665 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUHLDING I APPLICATION & PERMIT 09665
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
. r 'lalsOlq �$ �x/Iq
NAME a1 Uit7 QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
• E
CONTRACTORS ACTOR -OUTLETS,SWITCHES•RECEP 10.00/1.00
Uc.ND. LIGHTING FIXTURES 10.00/1.00
CONTRA O
�pqE w(D�C7 I APPLIANCES-RESIDENTIAL 4.00
V ONE J PANELS 10.00 DATE OF APPLICATION
OORRCHIrscr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS END' SPECIALCIRCUIT 5.00 PERMIT VALIDATION /
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH, /)
IK�
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7 00)of Division 3 of t e Bus/tpe��sand
a < /1 BLDG. ELE❑LT. PLG. MECH.
w i Professions Cod
d n •nse is in full fart a Iwo., /-
o i w o Licenyr(jlass
r m L J Dale�� Contractor �
Q Y J BUILDING PERMIT
Ic a w u OWNER-BUILDER DIiCLARATION INFORMATION
X ;' r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F LL O dU Law for the following reason.(Sea 703 1.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
I �>f Code:Any city orcounty which requires a permit foconstruct,alter,
I[ ¢ Q Dimprove,demolish,or repair any structure•prior to its issuance,also ELEC.CONTIL LIC.N0. ELEC.
D a: requires the applicant for such permit to file it signed statement that - TOTAL PERMIT TO
n w$ he is licensed pursuant to the provisions of the Contractor's License �)
r z i Law(Chapter 9(commencingwith Section 7000)ofDivision 3 oflhe Z-13 �.
z o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
W H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Growby any more
horfive permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
o(not more than Clvc hundred dollars(ES00).)r
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sola compensation,will do the work,and the structure is not OCG GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractors 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 TOTALALREAGE
• himself or through his own employees,provided that such improve.
merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner - . • . .00- GAS EASYSTEM OVER 4(EA) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
0 1,as owner of the property,am exclusively contracting with ❑ 1:1 E] ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'he 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($)licensed pursuant to SEWER-SAN V-STOflM EA.200ft/10,00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. - ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason -
Ownar Dute WATER$Y$ 5.00 ACC.DATE ACC.FILE N0.
WORKE RS'COMPENSATION DECLARATION WATER TREATING EQL. lg. 5.00
I hereby affirm that I have a c nfica to or consent to self-insure,
ora certificate of Worker' pensation liomwc �d lJ ZONING ENG.SITE NO,
copy
Nre man .E�Lt�I�l�j e�,P\r�a ce�rtifie
oc
O rti0ed copy is hereby furnished. I FIRE SPANK ENERGY T-24
Z 2 •rtificd cy is filed lh tl ell ms •coon division.
F0 Applicant - g p psrvs�.F, MISC.- REFER TO ORD. Y N� v ❑ N0
w CIiRTI CAT60('EXCMP710N I•AOM WORKERS' PERMIT ISSUANCE 10.00 FLOOD
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO,
Z CL (This section need not be completed if the permit is for one TOTAL Y E]
hundred dollaa($100)or leas.)
U 0 1 certify Nat in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL i- mil is issued,I Shall not employ any person in any manner So as to
OUbecome subject to the Workers'Compensation Laws of California.
Q. Date Applicant BUILDING
} w NOTICE TO APPLICANT: If,after making(]its Certificate or Ex- ALTER OR ADD TO MECH. 5.00
F Z emption,you should became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 100MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.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
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 r
information n estate l 1 agree to comply with all city and county BOILERLUMBING �.
ordinances and store laws relating to building construction, and (3 H.P.H.P,Or 100,0000.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. g01 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City o1 MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
maVing
in any way accrue against said City in con use of the
this permit. MECH.CONT. LIC.NO. MECH.) TOTALTOTALof Applicant/Conlrnctnr U (c
OFFICE COPY