C 8596 R
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ONPE IT NUMBER
aUILDING • APPLICATION & PERMIT g 5 9 6
ADDRESS O !7s , /
WC« '3 BUILDING-ELECTRICAL-PLUMBING -MECHANICA
OWNER'S PLAN CHECK VALIDATION
• "4ME76,_ pENNEj DTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR'S
"AME EGD NUM`i SPEIuKLCP- OUTLETS-SWITCHES-RECEP 10.00/1.00
o Uc.ND,G-iC 36JC LIGHTING FIXTURES 10.00/1.00
ADDRRESST I0 �60 1.t,CIO ALIO APPLIANCES-RESIDENTIAL 4.00
C,ILIZQ�IrA /66219HONE 817-097 PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR I-.
ENGINEER
LIC.NO ISIGNS TRANS. ! 3.00
ARCH,OR ENG. 5.00 PERMIT VALIDATION
ADDRESS ISPECIAL CIRCUIT I
ZIP EMP.METER OR POLE INS. /' 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 </ A
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �4 zI O
a WO w I hereby affirm that I am licensed Order provisions of Chapter 9 ISSU NDE DATE
so a m (commencing with Section 7000)of Division 3 of the Business and ggg��l,,,o& T. PLG. MECH.
H wn Z Professions Code an I y license is in full force a d f ❑ ❑ ❑
Z o m - License �s - b Lie Number ' u
Q Z w Date Contractor
¢ y s BUILDING PERMIT
¢ ¢ w ¢
OWNER-BUILDER DECLARATION INFORMATION
wo¢ LI MISC.- REFER TO ORD
;LL H I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
Lo ¢ Law for the following reason.(Sec.703L5,BusinessanJ Professions PERMIT ISSUANCE 10.00
E w Code:Any city or county which requires permit to construct,alter, 1 �.�...�
¢ ¢ < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ✓
O ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO CM
wes w he is licensed pursuant to the provisions At the Contractor's License
HZi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe y
¢ Business and professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE / E '
¢ H D the basis for the alleged exemption.Any violation of Section 7031.5
STORIES TYPE CONSTR.
5_: applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP REB.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Safe (Sec. 7044, Business and cmfivoioas 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 F IXTUR ES-PER TRAP 5.00 SO.FT FLOOR AREA AGE
• himself m through his own employees,provided that such improvo
ments mselfo through
ot or employees,ffered for provided
ed 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 BUILDING uSE
builder will have the burden of proving that he did not build or im . . . RES IND CON PB Omar
prove for purpose of sate.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,or exclusively contracting with ❑ ❑ ❑ 11licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PA RCE
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 contradons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Iamexemptunder Sec. ,B.&PC.ro'll's WATER HEATER W/VENT 6.00 �C
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILEN0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING
or a cerlifiwlc of Workers Compensation Insurance,or a certified ENG.SITE NO-
urpyY hervetof jSsci800.ecoump
Lab.C-
colic No ( Cany
❑ Cenified Copy I'he famished \ FIRE SPRINK ENERGY T-24
Z Z ❑ C5+�y'� c i f �q �y the city inspection division.
O Applican y^e ,/�4I'// - MISC.- REFER TO ORD. Y ❑ N❑ Y ❑. N❑
T 41FICA� PERMIT ISSUANCE 10.00 FLOOOZONE A.L.uc.
LU C6 TIPICCOMPE EXEMPTION PROM WORKERS'
W � COMPIiN5AT10N INSURANCE PLG.CONTR. LIC.NO. PLG,
CL O (This Section need not be completed if the pen..it is for one TOTAL Y❑ No Y❑ N❑
D Z hundred dollars IS 100)or less,)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued.1 shall not employ any person in any manner so as 10
V become subject to the Workers'Com ensation Laws of California.
O w Date-Applicant Applicant p BUILDING �
a ALTER OR ADD TO MECH. 5.00
} rn NOTICE TO should
If,after making this Certificate pe sa Iix-
F-. ? emptio n you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK or7
provisions io the Labor Code, you must forthwith comply with FEE .3
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 1Op00GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0MC.F.M.) 6.00 SEISMIC FEE ( G�
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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097.Civ.C.1.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lendcr s Address
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-COMPI3 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 agar sl Said City in consequence of the PERMIT ISSUANCE 10.00
grantin !this perm' MECH.CONT. LIC.NO. MECH. �/ ye/
7 g,�r TOTAL TOTAL P TT
Sgn ore of Applicnt/Con mcmr Dale O V✓
OFFICE COPY