09558 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BA POINT PEN ONLY
BUI LDI NO PROJECT I DENTI FICAT . PERMIT NUMT
-APPLICATION & PERM09558
1
� oREss
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
WNE '9
NA E PLAN CHECK VALIDATION
// OTY. ELECTRIC PERMIT FEE
eL PHONE
NAMERACTOR's a UTLETS-SWITCHES-RECEP 10.00/1.00 Q
'�lg.0ti 13&d d uc.No3Zab L 33 LIGHTING FIXTURES 10.00/1.00
�AEDDRREESSSSTD aQ E� PPLIANCES-RESIDENTIAL 4.00
p�/OO /J �NE f..I PHONE 996-31ZZ PANELS ' 10.00 O� DATE OF APPLICATION
oncHITECT PANELS(OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.NO. SIGNS TRANS. 3.00
ono'Ess ENG' SPECIAL CIRCUIT 5,QQ PERMIT VALIDATION
zIP EMP.METER OR POLE INS. 20.00 R
ADDRESS APPLICANT'S MOTORS SEE FEE SCH.
pEgS
.Z1Q R Tr SERVICE CHANGE 20.00 /, ,/&S
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 f9/ O
<i I hereby effort that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
In< A BLDG. ELECT. PLG. MECH.
H y i Professions Codc d my license is in full for eL'ec -s
2 0 - License Class Lic.Numb b frA'/ll
0 z w Dafc.L/_= Contraclo
P
Y s BUILDI GWERMIT
¢ ¢ic OWNER-BUILDER DECLARATION INFORMATION
X I- I hereby affirm that 1 am exempt from the Conlracloh License MISC.- REFER TO ORD
wa. o¢ Law forthe following reason.(Sec.7031.5,Business and Professions VALUATION g/FT.
Ww� Code:Any city orcounty which requires a permit to construct,alter, PERMIT ISSUANCE 10.00 Q `,
> ELEC.CONTR. LIC.NO. D
¢ ¢ ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC. /�
i 0 LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w rem he is licensed pursuant to the provisions of the Contractor's License ��
Hi >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TV PE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty ALTER & VENT-WATE A. 5.00
of not more than five hundred dollars(S5000.):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEV 4'.00 OC GROUP RES.UNITS
their sole Conine,
um pensation,will do the work,and the structure is not /
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,C O. 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 ;.y 5.00 SO.FT.FLOOR AREA-TOTAL ACREAGE
himself re through his own employees,provided that such improve-
mentserenotintcndedoroffereoyeesalc.Tided that suhempro ng GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im . BUILDING USE
I
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 NO CON PB Omer
❑ Las owner of the property,am exclusively contracting with 0 0 ❑ C]
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASGESSORSPARCEL 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 -Q
contracts for such projects with a contractods)licensed p inuum to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tum exempt under Sec..,BARC.for this
reason WATER HEATER W/VENT 6.00 _
r Owner Dam
WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
Its WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ufcoment to self-insure, ZONING ENG.SITE NO.
or¢aycertificate of Workers'Compensation Insurance,or a certified
Q�CYth c f Se 38CO�Iab.CJ. IGTNA
CY p Y
❑ citified 'u yis hereby furnished. FIRE SPRINK ENERGY T 24
_Z Z s�Certifwd co Is filed ' s the city inspection division.
HO AMISC.- REFER TO ORD.
ppbcant ry V E] NC] Y[:3N�
CC yPERMIT ISSUANCE 10.00 6 FLOOD ZONE A.L.U.C.
CERTIFICATE O EXEMPTION FROM WORK17RS'
LL > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
d / y N Y No
O (This section need not be completed if the permit is for one TOTAL s0
::) Z hundred dollars(S1OO)or lesa.)
U O 1 certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Ubecome subject to the Workers'Compensation Laws of California.
0_Iu Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDINGSS��
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex
F ? emplion,you should become subject to the Workers'Compensation-
APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
C.) such provisions or this permit shall be deemed revoked. AIR HANbLING UNIT ITO 10p00GF.NL) 4.00
J CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 u
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 6 �/
Lender's Address ELECTRIC 7 ,Z
I certify that 1 have read this application and state that the above 4t 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 r
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IDVar t00,00D BTUI SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX OV
ma ny way accrue against said City in consegyence the
gr retire his MECH.CONT. LIC.NO. MECH. OL
�j TOTAL T�9 TOTAL //Fe
f G/
Sig
nature of pplicant/Contractor Dale
OFFICE COPY