9238 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
L BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
�T DIIILDING 7C ane/(]n N n� / / )�f / 9238
ADDRESS `-7/ (•CT /L/y/'/ 5/5/ ✓�C//
QUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER' PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• T✓77
rf 4/ H E
corvTRAcr R _
OUTLETS
-SWITCHES-RECEP 10.00/1.00
N E / /�
�(� O 'ti ✓ Lie N . 6 / LIGHTING FIXTURES 10.00/1.00
roNTRAcroR'sPPLIANCES-RESIDENTIAL 4.00
ADDRESS_
fh/IfH6Nr i LUf PANELS 10.00 DATE OF APPLICATION
ARCHITECT 1 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARC H.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP rFEMP.METER OR POLE INS. 20.00
APPLICANTS IMOTORS SEE FEE SCH.
ADORE 55
SERVICE CHANGE 20.00 y ,{p
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 / " 5
a u I hereby affom that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o
Professions ode�ndm •license is in full fur •aI -lVc�/ ❑ ❑ ❑
z o'w License ss -Y! Lic.Number.
o H O Uate Contractor
Q y J
¢ ¢w ¢
OWNER-BUILDER DECLARATION BUILDING PERMIT
o A D MISC.- REFER TO ORD INFORMATION
E
;u y I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
H u o 4 Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to construct,eller,
ar ¢ ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
iiine requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A ,e m" he is Jicensed pursuant to the provisions of the Conm¢tor's License w
Hii Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
¢ Business and Professions Code)or that he is exempt therefrom and GZ. PLUMBING PERMIT FEE
/�
¢ r$ the basis for the allege)exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner ol'the properly,or my employees will'wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. '5700
Code:The Contractor's License Law does not apply to in
n owner of
property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP -SIBO 50.FT,--FLOOR TOTAL ACREAGE
himself or through his own employees,provided that such unprove-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 16,00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA,1 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ El 11❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLE 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'hc Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER A.) 1.00
contracts for such projects with a contractorts)licensed pursuunt to
the Contractor's License law. SEWER-SANIT Y5 IgM A. 00EQI0.0 TRACT NO. PARCEL NO.
❑ 1 ant exempt under Sec. .B.&P.C.I'..this WATER HEATER VWVENT 6-80
reason peftivio
Owner Date 1 WATER SYSTEI%Ity 01 uu Sao ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION UIiCLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of cousem to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy there c. O lab dd `Pv ,-./x pzO p1
Policy No.3-Qom aY
O ❑ Certified copy Is her$y rnished. FIRE SPRINK ENERGY T 24
Z_ 2 ❑ Certtjtfti ir• d witl�/jftE�dtYsprn division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applic:m lL 1 ate'- V N v N
F- N ,4 PERMIT ISSUANCE FLOOD ZONE A.L.U.C.
0 CERTIIICATI:01'EXEVIPT10N FROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
D' 0 1'I his suction need not be completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
Z hundred dollars IS 100)nr less.)
U O A certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers''Compensation Laws of California. BUILDING
W Date Applicant ALTER OR ADD TO MECH. 5.00
To NOTICE TO APPLICANT': If,after making this Certificate of Ev-
? coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most Forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I 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
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Addreas
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a lost liabilities,judgme s, costs and expenses which CONST.TAX
may in an way a e against d City in consequence of the PERMIT ISSUANCE 10.00
graining thisp, IL MECH.CONT. LIC.NO. MECH.
p TOTAL TOTAL
Sign t re fA 1 cant/Co.1 r Date
OFFICE COPY