9090 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
A DORESEE /
c7d�Sv/eH DING-ELECTRICAL-PLUMBING-MECHANICAL 9090
OW V Ea' PLAN CHECK VALIDATION
NAM QTY. ELECTRIC PERMIT FEE
PHDNEa
NAME ACTORS ! UTLETS-SWITCHES-RECEP 10.00/1.00
C4 �IrSv,/ -44'SLIc.No. 4o LIGHTING FIXTURES 10.00/1.00
NT eSTORS y1S APPLIANCES-RESIDENTIAL 4.00
Haf ,` r IPHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR -_ PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG _ SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
�- ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS TS �- MOTORS SEE FEE 0.00SCH. �f
SERVICE CHANGE 20.00
'02 LICENSED CON'TRACTORS DECLARATION TEMP.POLE 30.00 S"�/G/per
M a. I hereby affirm that 1 mn licensed under provisions of Chapter 9 r 10
H a$ lamm�encing with Sctian 70001 of Division 3 of the Business and ISBUA CE DATE
G. ELECT. PLG. MECH.
O z T o Professions C m my license is in full force and effect n ❑ ❑
z o m- License ss s. Number `
m H w Datc - __:4�CmnractorT-e Iles Aft ]
Q w¢ OWNER-BUILDER DECLARATION )71
BUILDING PERMIT
e- °'U MISC.- REFER TO ORD ATION
w ; I- I hereby affirm that I am exempt from the Contractor's License
u O a Law for the following reason.(Sec.7031.5,Business and Professions qViATION $/FT.
- PERMIT ISSUANCE 10.00
Code Any city or county which structure permit to construct,,also
ac rE af improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u w m LL - requires the applicant for such permit to file a signed statement that TOTAL
he is licensed pursuant to the provisions of the Contractor's License PERMITTO
Hza Law(Chapter 9(commencing with Section 7000)ofDivision 3 of theAl
s r D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE IC
s- m the basis 1'Or the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
U by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT.DEVICE 4.00
!Itch Sole compensation,will do the work,and the structure is not 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 do"such work FIXTURES-PER TRAP 5.00 SD.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
, ments are not intended molt..d for sales If,Imwever,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
ur improvement is sold within one year Of completion,the owner - . -
- GAS EASYSTEM OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or an- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Omer
CI 1,as owner of the property,am exclusively contracting with El El Cl 1:1 El
contractors t0 construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.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-OVER 5(EA.) 1.00
conlracts,fornuch projects with a contractors)licensed punuant to
the Coact 's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
�OetrorInm exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 -
ACC.QATE ACO FILENO.
WORKERS'COh7PIiNSAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 Imreby affirm that 1 have a certi0cate of consent to self-insure,
ora certificate of Workers'Compensation Insuranpe,ora certified ZONING ENG.SITE NO.
copy thereoff5ee.3800.Lab.CJ. _p
Policy No.-Company-
0
o. Company /! T
O ❑ Certified copy is hereby furnished.
Z Z copy city inspection division. FIRE SPRINK ENERGY T-24
❑ Certified o is fled with the cit
Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ NQ
CC O PERMIT ISSUANCE 10.00
Lu - CIiRT1E1CCOid OF FROM WORKERS' FLOOD ZONE A.Lu.C.
(L COMPfiNSAT'ION INSURANCE
PLG.CONTR. LIC.NO. PLG.
d O 1'rhis section need not be completed if the permit is for one TOTAL Y[:] N❑ Y❑ N❑
Z hundred dollars($100)'OIess,)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to FEE
O W become subject to the Workers'Compensation Laws of California.
ED NO p
Applicant
ED NOALTER OR ADD TO MECH.' 5.00 BUILDING 1
} TICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emotion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit MIA be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000O.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
30H7,CIV.CJ' HEATING UNIT(70100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
LI certify that 1 have read this application and slate that the above VENTI LATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordimmes, and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to cuter upon the
ahove-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE$CH. MECHANICAL
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against ImbIIHIc judgments, costs and expenses which CONST.TAX
may in any ay accrue ,.at
said City in consequence of the PERMIT ISSUANCE 10.00
granting of s rmit.
MECH.CONT. LIC.NO. MEGM.
` _ !;`15' 1 1 -E I
TOTAL TOTAL
are of ApplicUale
- ) - OFFICE COPY