9083 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BOILDING APPLICATION & PERMIT 9083
AOD Es,S G� � �^ _/• BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwNEP(5 (•' CL PLAN CHECK VALIDATION
NAME OTY.. -ELECTRIC PERMIT '. 3FEE':
��IA'AI'd ar PPDNLC& - 7/
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
ME r1 '
IV '- y LIGHTING FIXTURES 10.00/1.00
L NO.
ro TRACTOR('S'� PPLIANCES-RESIDENTIAL 4.00
�y L PVONE�/rlJC�y Fi�C! PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.O.NO,
OR
ENGINEER LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
zu, TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 {,//,
w
-00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 d// S
a u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G oAi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
r a 2 Professions Code.and my license Is in full force and effect. / ❑ ❑ ❑ ❑
0 o w- License Class_��e/.��Lie-.Number - D
N H w Date../�=� Cnn Contractor �'�
:,BUILDING P.ERMIT.;"'_Ys�`?
a wu OWNER-BUILDER DECLARATION I N FO RMAT10N,1
iw3 LL m I hereby affirm that 1 am exempt from the Contractor's License MISC.- C EFER TO ORD _
uoa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 O VALUATION 5/FT.
Code:Any city or county which requiresa permit to construct,alter, N0. �9 �i a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.DONTR, UC. ELEC. 674N
o LL requires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License ,.,-.pq
ii Law(Chapter9(commencing withSection7000)ofDivision3ofthe - "' '" 'G^ RHE
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT ='-" FEE:.
3 2 O _ STORIES TYPE CONSTR.
it L$ the basis for the alleged exemption.Any violation of Section 7031.5 7 -:'.-1 T "
A _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
c not more than fwe hundred dollars(S500).):
❑ 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,AR EA,COND. 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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments a or not intended or offered for sale.IE however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
t or improvement is sold within one year of completion,the owner-
' builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 RES IND BUILDING CONPBOther
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ h as owner of the property,am exclusively contracting with ❑ ❑ 0 0 1
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 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.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL N0.
the Contractor's License Law.
❑ Iumexemptunder Sec. .B.&P.C.f.,tho WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self insure. FON IG ENG.SITE NO.
or a certificate of Workers'Compensation In��su�ran'ace,yr a certi0ed
copy thereof Sec.3800,Lab. w l �-aU \nws4 Y
Policy No. Company}-3-- a1
Q ❑ Certified copy lslxxby lurmshct P4?43Fzq jJI FIRE SPRINK ENERGY T-04
Z Z ❑ Celt co y Is filed II the ins ecuo clivi ion. MISC.- REFER TO ORD. y N y ❑ No
Applicant�ty�-r' I,
F- PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COM
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. TOTPLG. L v C3N[] Y❑ N�
�- 0 (This Section need not be completed if the permit is for one A
� Z hundred dollars 14100)or less.) - ' - c• 1 .i• " w - W 4
U O 1 certify that in the performance of the work for which this per- - o?'`>t• FEE SUMMARY+"`b"a'-+
ly H mit is issueJ.I shall not employ any person in any manner so as m OTY. "MECHANICAL PERMIT,'��,;�;�..,; FEE.
O W become subject to the Workers'Compensation Laws of Cxlll'orma. •` BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} h 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,OODGF.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 MICROFILM
the performance of the work for which this permit is issued(See. HEATI"000O 100000 B.T.U.) 8.00
3097.Civ.C.1.
Lender's Name HEATVER 100,000 B.T.U.)9.50 ELECTRICLender's Address
I certify that l beverexd thisapphcation and state that the above VENTN (SINGLE) 4.00 PLUMBING
infornation is correct. I agree to comply with all city and county BOILEP,or 100,000 B.T.U.) 6.00ordinances and state laws relating to building construction, and
hereby authorite representatives of this city to enter upon the BOILEer 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 against liabilities,judgments, costs and expenses which PERME 10.00 CONST.TAX
ma inany way accrue agamxt,$ad City in consequence of the it Of thi' cnllil. �(7 - MECH.CONT. LIC NO. MECH, i,(ffJ(/a..._. _ ,( TorgL :>:TOTAL
'Ignature of APPlican UContractor Date
OFFICE COPY