09796 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROD CT I DENT[FICATI ON . PERMITNUMBER
AoDDWINGS /0%23 OLFv- v APPLICATION & PERMIT 09796
I C N BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER 5 PLAN CHECK VALIDATION
NATE QTY. ELECTRIC PERMIT FEE
/ L l m r ` PHONE
NAMQRAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
4 vISrA O Um.No ( � LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS-1 LJr rj /y�S /,({ /��//
5 ! �• PHVONE�Y54166 PANELS 10.00 DATE OF APPLICATION
ARCHITECT ftfi 1/..1 a eL PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.0.NO.
OR N �I
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
AARCH
DDREOS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PTLD
APPLICANTS MOTORS SEE FEE SCH.
ADOR ESE O/1
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Ci
��/�1`/�
IF u I hereby affirm that I am licensed under provisions of Chapter 9 ISS 1rANL'Ef
may (commencing with Section 7000)of Division 3 of the Business and D ELECT. PLG. 6tH.
Professions Code,and my license is in full fomc f ❑ E] ❑
License Class Lic.Number
2 H w Uate_Jo_(--B�Conlruclor L
a y E BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
X ;u N I hereby affirm that I am exempt from the Contractor's Lssions
MISC.- REFER TO ORD INFORMATION
LLOa Law for the following reason.(Sec.703L5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
2 - � Code:Any city or county which requiresa permit toconstruct,alter,
¢ G¢ FO improve,demolish,or repair any structure•prior to its issuance.also ELEC.CONTH. LIC.NO. ELEC.
0¢ requires the applicant for such permit to file a signed statement That TOTAL PERMIT TO
wm U. he is licensed pursuant to the provisions of the Contractors License �•
Hzi
Law(Chapter 9(commeocing with Section 7000)of Division 3 of the `
- ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects the applicant toes eivilpenally ALTER-DRAIN -WATER IEA.) 5.00
' of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCL.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,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.PT.FLOOR AREA TOTAL ACREAGE
himself'Dr through his own employees,provided that such improve-
b • ments are not intended or offered for sale.If,however,the holding GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is cold within one year ol'.completion'the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILmN uSE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND v9 Other
❑ I•as owner.1 the property,am exclusively contracting with ❑ ❑ N ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSES7&RCELNO.
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 u contmetods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt umler Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
owner Date WATER SYSTEM 5.00
ACC.DATE ACL.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certi0cme ofc.oScDt to self-insure' ZONING
or a certificate of Workers'Compensation Insurance,or a certified ZONING SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. ComPanyiPWJ FUnJ�
Q ❑ Certified copy is Immby urn ishcd. FIRE SPRINK ENERGY T.24
Z zI ❑ Certi'ied 'opy is filed with the city inspection division. MISC.- REFER TO ORD. Y ❑ No Y ❑ N❑
My CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUA 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. UC.NO. PLG,
CL O (This section need not be completed if the permit is for one TOTAL Y❑ IN Y ❑ N❑
0 Z hundred dollars(S 1001 or less.)
U O 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L H mit is issued,I Ondl not employ any Rcnun in any Danner so as to
U become subject to the Workers'Compensation Laws of California.
U D. Date-Applicant BUILDING
D. ALTER OR ADD TO MECH. 5.00
} m NOTICE you
shout become
If,after making This Certificate of ion
F- ? tanprion,vision you shouldbecome subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK �n
provisions io the Labor Code, you must forthwith comply with FEE 0
U such provisions or This permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirin that there is a construction lending agency lit. EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work]or which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property 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 any way accrue against said y in consequence of the PERMIT ISSUANCE 10.00
grantin Of this rel' MECH.CONT. LIC.NO. MECH.
D_ _ TOTAL TOTAL
Ignature o pplicant Contractor Date
OFFICE COPY