09639 (2) APPLI ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU ILDING PROJECT IDENTIFICATION PERMIT NUMBER
RUILUING - APPLICATION & PERMIT
°°pREss 09639N BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR
NAeNact°Rs rr �f ,r7 OUTLETS-SWITCHES-RECEP 10.00/1.00
V)eS G LIC.NO,,2 Q / LIGHTING FIXTURES 10.00/1.00
COONTTRASCTOR'S N'r j APPLIANCES-RESIDENTIAL 4.00
�'/ D r Qj PNG NOL+yf�1_3,I. 'PANELS 10.00 DATE OF APPLICATION
OAC rcacT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Lie NO, SIGNS TRANS. 3.00
ADDRESS era.. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLI C ANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
awo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 P
U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N a u (commencing with Section 7000)of Division 3 of the Business and B�� L�T� 1 [ MECH.
F O i Professions Co and I 'cense is in full for Jof �L�J.x77
o i L O Licen lass Lic.Num
Dale ^ Corti: r
Quf < IT
¢ O n O OWNER.BUILDER Dli ATION C ION
K ; LL m 1 hereby affirm that I am exempt f m the Contractor's License MISC.- REFER TO ORD
01 a.O< Law for the following reason.(Sec.7031.5,Businessaod Professions VALUATION
- u � Code:Any city or county which ra aures..perinil toconstruct.atler, PERMIT ISSUANCE 10.00
1 ELEC.CONTR. LIC.NO.
Q cr ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O e requires the applicant for such permit to file a signed statement that TOTAL
a. w $ he is licensed pursuant to the provisions of the Contractor's License PER T TO
H z < Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe M
4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE r
M r the basis for the alleged'exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500),): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of Bre property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will d°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 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 Ilist such unit......
ments are 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. GAS EASYSTEM OVER 4 IEA) 2.00
builder will have the burden of proving that h - . •
e did not build or im- BUILDING USE
prove for purpose ofsale.). 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,RosinessLAWN SPRINKLERS- i INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
Io an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractora)licensed pursuant o SEWER-SANITAR V-STORM EA.200(1/10.00
.tire
Contractor's License Law. TRACT NO, PARCEL NO.
❑ tum exempt under Sea ,B.&Poco for this
assn WATER HEATER W/VENT 6.00
Owner Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WOkKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate or consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
.co y thereof(Sec.3800,Co nah.Y.)�__ ( / TA_
is Na Com an ea,Sia rte! C -
ertil ies{L y is hereby rami' - FIRE SPRINK ENERGY T 24
Z Z ❑ Certified a s RIe wi he , y s riygc ql Aivision.
O A ph ant p-'L�� MISC.- REFER TO ORD. YC] No Y E] IN
~ L) V PERMIT ISSUANCE 10.00
CFR'( CATS Olr IiXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
LL COMPI!NSATION INSURANCE PLG.CONTR, LIC.NO. PLG,
d O (This section need not be completed if the permit is for one TOTAL Y[] NC3 Y F] NE)
Z hundred dollars IS 100)or less.)
U O I certify that in the performance.f the work for which Dl's per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of Culifornia.
y Date Applicant BUILDING
>- to NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
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=C.F.M.I 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 -ev
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,cm.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 giV0
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN ISINGLE) 4.00
information is correct I agree tcomply with all city and county BOILER-OOMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives this city to
above-mentioned property for inspection purposes.enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against suit] City in consequence.f the
grunting of this permit. MECH.CONT:fIJ`j LIC.NO. MECH.
G63 TOTAL TOTAL
Signature of Applicant/Contractor Data
��.�
OFFICE COPY