9503 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
BUILDING PROJECT I DENTIFICATION PERMITNUMBER
..I1131NG .. APPLICATION & PERMIT 9503 .
?,\ noor s _0 TDING'-ELECTRICAL-PLUMBING-MECHANICAL
OwrvER'a PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
PRGNE7 q
•- ONTRACTOR6 -
I`v�TMAE ^ � ,{
OUTLETS-SWITCHES-RECEP 10.00/1.00
=I TIME f/ 1�luc.NAI ��3 LIGHTING FIXTURES 10.00/1.00
T (,ONTR CTOn'S
DDR s }y �T'�-��E PP LIANCES-RESIDENTIAL ' 4.00
RHONE'730'2,3 T PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS (OVER 200 AMP) 20.00
ENGINEER Lie.NO. ISIGNS TRANS. 3.00
ADDRESS ENG.• SPECIALCIRCUIT t S.00 PERMIT VALIDATION
,ZIP TEMP.METER OR POLE INS. 20.00 1
ADORESNTsSMOTORS SEE FEE SCH. �I
SERVICE CHANGE 20.00
w0 oLICENSED CONTRACTORS DECLARATION! TEMP.POLE 30.00 �rp
a u w I hereby affirm that I am licensed under provisions of Chapter 9• '
SSUA
H 2 NCE DATE
4 n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H 7 i Professions C e,and my license is in full fort a e f ElEl ❑
License lass Li,
.Numbe
H In�'J Dale Cramracto t
< Ya BUILDING PERMIT
M m i OWNER-BUILDER DECLARA ION INFORMATION
wI hereby affirm that I am exempt from the Contractor's License MISC.- REFER.TO ORD
u 0 a Lew for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
r - g PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
Pic
¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. L'IC.NO, ELEC.
O W requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X In he is licensed pursuant to the provisions of the Contractor's License /
F Z Q Law(Chapter 9(commencing with Section 7000)of Division 3 of Gte �L lJiL/8a/NG+
i c Business and Professions.Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
X I 'B the basis for the alleged exemption.Any violation of8ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant suit civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employeeswith wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS 4
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,CON D.. 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 FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided[lint such improve-
mentsata not intended or offered for sale.If,however,the building GAS-EA,SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner.
builder will have the burden'of proving that be did not build or at. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct [he project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 VB600 gSSEssogs PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B. .
to an owner of property who builds or improves thereon,and who. LAWN SPR INKLERS-O .1 1.00
contracts for such projects with a contractol(s)licensed pursuant to Q
the Contractor's License Law. - SEWER-SANITAR V-STO 000/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,BAP.C.for this
reason WATER HEATER W/V 5..00
Owner Date WATER SYSTEM 00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EMP g00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'COmPa.sa`ton�n,Owe,ora ified
copy thercof(Sec.3800,Lab.CJ sV1G TfT'xA`�'�4 :[7l6 S^ �� x
Policy No. Company
0 ❑ Certifredco"isbereby furnished.AAWJ I FIRE gPRINK ENERGY T-24Z ❑ Certified copy is filed with the city inspection division.
OJ Anplicant MISC.. Y[:] NY 0 N�
S CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUA '1 00 D. FLOOD ZONE A.L.U.C.
LU _ COMPENSATION INSURANCE PLG.OONTR. L O.At G4 � ) �
Z (This section need not be completed if the permit is for one (' lb t. Y O N� Y❑ NE]
hundred dollars($100)or less.) `-
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
Il I- mit is issued,I shall not employ any person in any manner so as to
C) W become subject to the Workers'Compensation Laws of California.'
Oast Applicant - BUILDING
CL ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject t0 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=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAODC.RM.) 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 ISce. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all,city and county PLUMBING -
ordinunces and state laws relating to building construction,and BOILER-COMP(3 H.P.Or 100,000B.T.U.) 6.00 ' Q ��
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree1.save, indemnify and keep harmless the City at MISC.- REFER TO ORD.
Cupertino egvnsI liabilities,judgments, costs and expenses which' CONST.TAX .
may in any way accrue against said City in'conseyuence of the PERMIT ISSUANCE 10.00 '
- Sr OI'f is permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignature of App icco"Cool, r Ua[
OFFICE COPY -