9423 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
GUI LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS �q� 9 4 2 3 ,I
ZIL(WZ x�TAW rIE' G JBILILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNED'S
NAME PLAN CHECK VALIDATION
0 1 _A _'�jrTY. ELECTRIC PERMIT FEE
n/ .ONE
CO TRACTORS
X NAME /�� UTLETS-SWITCHES-RECEP 10.00/1.00 /6 -
Llc.,No.Y'�3 /-7 LIGHTING FIXTURES 10.00/1.00
\^ CONTRACTOR'S PPLIANCES-RESIDENTIAL - 4.00 -
,X AOOR�S 0 or, ,733 kSeklo
>V PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
/:GC LIC.ND. SIGNS TRANS. 3.00
ADDRESS NG' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. rs 120:00 �" �"
ADDRESS TS MOTORS SEE FEE SCH. r•
SERVICE CHANGE
tf �e)�"f//'J/p?�
�00 . LICENSED CONTRACTORS DECLARATION TEMP.POLE `pp/TIRO
<u U I hereby affirm that I am licensed under provisions of Chapter 9 i r.1)ettln IS NC6 t met
(commencing with Section 7000)of Division 3 of the Business and - I BLDG. ELECT. PLG. MECH.
G,rn Professions Code,onlLmy license is in full force and effect I�I ❑
lot: License n _ _Con Number BUILDING
9 w r w Date Contractor
a u E BUILDING PERMIT
¢ ¢a NER-BUIIDE R DEC T
0 a v INFORMATION
v'x1 ; y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u 0 ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 10.00 VALUATION S/FT.
f w 0 Code:Any city or county which requires a permit toconstr Ct,Must,
re
¢ a O improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
m,
requires the applicant for such permit to file a signed Statement that TOTAL PER1lIT TO
n w he is licensed pursuant to the provisions of the Contractor's License
Fir La.(Charter 9(commencing with Section 7000)of Division3oflhe
s 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e. byxny applicant fora permit subjects the applicant too 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 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,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of -
property who builds orimproves thereon,and who does such work FIXTURES-PER TRAP5.00 JSQ.FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided that such'in
prove-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 . RES IND CON PS Omer
❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 Q�...y 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 J
contracts for such projects with a contructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ftll 0.00 TRACT NO. PARCEL NO.
C, I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 'l 6.00
reason '
Owner Date WATER SYSTEM ,5:00
(- ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP.^ P X5.00 '
I hereby affirm that I have a Certificate ofconsent tO self.insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof(Sec.3800,Lab.C. Of tlVYM
Policy No. Company
O ❑ Certified copy is h cobyf nished.0 FIRE BPRINK ENERGY T-24
Z Z Cl Certified copy is filedwith the city inspection division. MISC.- REFER TO ORD.
p Applicant v [:] NE] Y ❑ N❑
= y CCR FICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 U FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 9 /
CL Z (This section need not be completed if the permit is for one TOTAL 10 Y❑ N❑ v❑ N❑
hundred dollars(S 100)or less.)
U O I 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
U , become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE.TO,APPLICANT: If,after making this Certificate of Ex-
F Z emption,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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00CF.M.) 6.00 SEISMIC FEE 7
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
HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 p•p
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 700,000 BTU)BEE FEE BCH. 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
m in any way accrue against said City in co sequence of the PERMIT ISSUANCE 10.00
this permit. aMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sig aNf r
re oant/ Lor D e
OFFICE COPY -