10100 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT PERMIT NUMBER
DDRIIry/ APPLICATION & PERMIT
A6983 N .1�1� fid, 10100
�j ODREss BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
/ OWNER'S PLAN CHECK VALIDATION
NA"W- d v'i �(Q o �288a DTV. ELECTRIC PERMIT FEE
1�� HONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
TQ e Lt..N01I'?5 7 ILIGHTING FIXTURES 10.00/1.00
CONTRACTo s PPLIANCES-RESIDENTIAL 4.00
W
A Dfl �+ ''}�
IE 5 0 1 �N(y &4-PO
.H ry S _ PANELS 10.06 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
NGINEER
LIc,No. SIGNS TRANS. 3.00
AARCH.OR
DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 �f
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS /1/ys/�S
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U I hereby afrion that I am licensed under provisions of Chapter 9 , `ISSUANCE DATE
H <w (commencing with Section 7000)of Division 3 oI the Business' d BLDG. ELECT. I.G.PMECH.
I- m Z Professions Cod d--Corr license is in full folJ�IµIR�f S
¢ i H License Iass �L Lic.Numbers�'1_ ❑ ❑ '� ❑
Z' H w. Uatc- � Ir
F Conlmct
< x s BUILDING PERMIT
Cr ¢ce u OWNER-BUILDER DECLARATI INFORMATION
o a MISC.- REFER TO ORD
F
; H 1 hereby affirm that I am exempt from the Contractor's LIC¢mS¢ VALUATION $/FT.
H u o¢ Law for the following reason.(See.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city orcounty which requires perm it to construct,alter,
LE p Q Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
- o u requires the applicant for such permit to file u signed statenuenl that TOTAL PERMIT TO
w$ he Is licensed pursuant to the provisions of the Contractor's License
HZi Law(Chapter9fcom mencing with Section 7000)of-Division 3 ofthe f
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE g-Ig
or F $ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
a ; _ by any 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(SSOO).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
OCC.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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such Improve-
ments are not intended or offered for sale.I G howeveq(he building GAS-EA.SYSTEM-11NC.40 .00
or improvement
is within one year of completion, the owner. GAS-EASYSTEM-OVER 4( A.1 2.00 BUILDING USE
battler will have the burden of proving that he did not build Cor im- . RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE 1 NTER
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 IN .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-OV ER 5 E V
contract;for such projects with a Contractors)licensed pursuant to
the Contracmrs License Law. SEWER-SANITARY-STORM OOtt/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.titr this WATER HEATER W/VENT 6.00
ascan
Owner Date WATER SYSTEM 5.00
ACC.DATE PCC.FILE NO.
WORK ERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to srlflnSme' ZONING
or a certificate of Workers Compensation Insurance,or a certified ENG.SITE NO.
copy ther y[ *3&rt,.C.l. (� z edr{.t,
1'olicY'NO-T/f -3- puny�{!9
O ❑ CC,I d ropy is thereby furnrshed. FIRE SPRINK ENERGY T24
Z Z ty�CerFIwd copy is Bled with the city inspection division.
O Apcant MISC.- Lf AEFER TO ORD. Y ❑ N❑ Y ❑ N❑
F +✓� PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.u.c.
� CIiRT'IFICCOI PF EXEMPTION TINS PROM WORKERS'
11J D COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. /
d'0' (This section need not be completed if the permit is for one TOTAL 61 Y❑ N❑ Y ❑ N❑
::) Z h u mired dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F ...it is issued,1 shall nut employ any person in any manner so as to
U become subject to Lite Workers'Compensation Laws of California.
UJ Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NO'LICE'f0 APPLICANT: II',after making this Certificate of E.-
F ? amption,you should become 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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of (he 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 100,000B.T.U.19.50 ELECTRIC
Lender's Address
I ccrtity that l lmve read this application and state that the above VENTILATION FAN (SINGLE) 4.00
inl'ornation is Correct. I agree to Comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and 8OILER-COMP(3H.P.Orl00,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECHANICAL
ahovo-nicntioned 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 a wa again sl said City in consequence of the PERMIT ISSUANCE 10.00
granll D h ermil MECH.DONT. LIG NO. MECH.
TOTAL TOTAL
ign fApplica t/ ont or Uutc
OFFICE COPY