9081 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER AAPPLICATION & PERMIT
ADDRESS
9081
AODREss
C BUILDING_ELECTRICAL—PLUMBING—MECHANICAL
f 4„�
NAME PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
vHONE
I NAME Ac*Des UTLETS-SWITCHES-RECEP 10.00/1.00 /Cl
IC.ND LIGHTING FIXTURES 10.00/1.00
ADDRESS
DDRs APPLIANCES-RESIDENTIAL 4.00
A /�
PHONE O(9� PANELS 10.00 DATE OF APPLICATION
ARCHITECT�Qw� PLAN LHECK FEE P.C.NO.
OR
PANELS (OVER 200 AMP) 20.00
ENGINEER
Sec.NO.' SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADORE� MOTORS SEE FE B17
ADDRESS
.S ►�V�L SERVICE CHANGE 20.00'
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE O. s�
< u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D Z Professions Cod d my license is in full fore f• t ❑
o0 A o License ass Lic.Number -
F m H J DeleContmdor
ac ,e 2 BUILDING PERMIT
E ac w u OWNER-BUILDER DECLARATION INFORMATION
w 3 u I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
VALUATION I/FT.
Fun.) Law for the following reason. 7031.5,BusinessandProfeslfons PERMIT ISSUANCE 10.00 6 CIO
iw0-1 Code:Any city or county which requires a Permit to construct,alter, /8
)"Soo
improve, orrepair any structure,prior[o its issuance,also ELEC.CONTR. LIC ND. . ELEC. /Jr GO /`—'I
wDLL requires the applicant for such permit to file a signed statement that r- 358 473TOTAL W �t�PERMST Tq
$w he is licensed pursuant to the provisions of the Contractor's License (,;BY '—ICL77
FZ> Law(Chapter 9(commencing with Section 7000)of Division 3 of the /
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
H$ the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant ma civil penally ALTER-DR AIN III VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 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,AREA,COND. 5.00
Code:.The Contractor's License Law does not apply to an owner of
4 7„ ;n property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 0 a0.FT.FLOOn AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-l OUTLETS 6.00
marls are not intended or offered for sale.If,however,the building
rl
or improvement is sold within one year of completion,the owner-
s /✓ builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
s prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REs IND CON PB omer
” ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 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;0Q A
contracts for such projects with a contractors)licensed pursuant to SEWER•SANITARY-STOR 2 Yl .00
the Comotctoi s License Law. TRACT NO. PARCEL NO.
❑ lain exempt under Sec. ,B.&P.C.for this WATER HEATER W/VEN 6.0
reason
Owner Date WATER SYSTEM
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have acertifscaleofconsenl toself-insure' ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO..
copy lhereof(Sec Co Lab.C,h pr ATr AMFQICA
Policy No. Co hereby
i1
Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY t44
Z Z IYCertiOed copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y E] N❑ Y❑ NE]
� N CERTIFICATE OF EXEMPTION I*ROM WORKERS' PERMIT ISSUANCE 10.00 edam- FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTRR_ L O PLG.
1 O (This Section need not be completed if the permit is for one TOTAL a.240 Y❑ N❑ I Y❑ N❑
Z hundred dollars(SI00)or less.)
U O 1 certify that in the performance of the work for which this per OTY 'MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers Compensation Laws of California.
.
0 y Dat.—Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate Of Ex- -
F 2 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
V suck provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT((*WfdDMC.F. .) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH UC G lr 5.00 r�
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT IT,, A0, O'B.T.U.) 6.00
Leader's Name HEATING UNIT(OVER 100a . 9.50 ELECTRIC a�l
Lender's Address
1 certify that I have read this application and slate that the above VENTILATION FAN & 4.00
information is correct.1 agree to comply with all city and county PLUMBING 6
)� ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the /,
above-mentioned property for inspection purposes. BOILER-COMP(O r 1 OTUI SEE FEE ICH. MECHANICAL
�•� (We) agree to save, indemnify and keep harmless the City of MISC. EFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE` 10.001 CONST.TAX
may in any way accrue against said City in consequence of the
granting ofe&is p 't. MECH.CONT. LIC.NO. MECH.
Signature of Applica mdractor Date
Lx1L. L 398a-rz TOTAL �S- TOTAL 7 0
OFFICE COPY