8860 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
aU,L�,NG APPLICATION & PERMIT r 0
A69 FSS '7
rr L vc Ln 1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL b
OWNER'S PLAN CHECK VALIDATION
ME QTY. ELECTRIC PERMIT FEE
t PHONE
Name Acr9Rs pOUTLETS-SWITCHES-RECEP 10.0011.001.20 L uc.No. LIGHTING FIXTURES 10.00/1.00 ad`
CONTRACTORS
ADDRESS
A �-APPLIANCES-RESIDENTIAL 4.00 ^
CO
1HONf9ff-kaM '5-:PANELS 10.00 DATE OF APPLICATION
ARCHITECT
SQ.J �O[„ �S1^3 �� PANELS (OVER 200 AMP) t20.0Q PLAN CHECK FEE P.C.NO.
ENGINEER N X177 ��r L
LIC.NO, SIGNS TRANS. 3.00
ARCH OR ENG. SPECIALCIRCUIT S.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLI - MOTORS SEE FEE SCH, �- ,�/J
ADDRESS SERVICE CHANGE pmub.00
w o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.90 - ! /6
M Ef w I hereby affirm that I am licensed under provisions of Chapter 9 U `� ISSUANCE DATE
vHi a e- (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions C.dCJ shy license is in full far ❑ ❑ ❑
License Class Co N Contract.,, ff
o m w Dale,-��� Contractor C;ty Of Cup
a m s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ w u INFORMATION
E:
-A E. I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
H u 0 j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 C)---
m� Code:Any city or county which requires a permit to constmet,alter,
rea o, improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC. q �, 1 _
In
E: p ¢ requires the applicant for such permit to file a Signed statement that TOTAL �V o� PERMIT TO
w m m he is licensed pursuant to the provisions of the Contractor's License
F z s Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe SLG G7
4 o Business and Professions Code)or that be is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ h m the basis for the alleged exemption.Any violation of Section 703 IS STORIES TYPE CONSTR.
s;_ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -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,AR EA,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 F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mems 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 owne -
builder will have the burden of proving that he did not build or imr- GAS EA.SYSTEM-OVER 4(EA.) 2.00- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessLAWN 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 properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.POLE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insum, ZONING ENG.SITE N0.
or a certificate of Workers'Compen�saa✓tiovonnn Insurance,
,000r✓a certified
copy thereof{ "Wi pab.Y.1�/r/Y
PolicyNo. 00, an
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T44
Z Z CerliR c py is filed with the city inspection division.
PO A lican MISC.- REFER TO ORD. Y [] N� v� N�
L %O PERMIT ISSUANCE 10.00 PLOODZONE A.LU.C.
LU CERTIFICATE E EXEMPTION FROM WORKIi
W � COMPENSATION INSURANCE PLG.CONTP. LIC.NO. PLG.
0- Z( This section need not be completed if thN
e permit is for one TOTAL Y❑ C] V N�
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY, MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California.
y Date Applicant BUILDING
r } In NOTICE.TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F. ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10. 00CF.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,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 C.)6 Z
Lenders Nam Address ELECTRIC
I certify that 1 have read this application and state that life above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over/00,000 BTUI 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 anJ expenses which PERMIT ISSUANCE 10.00
AgrMITYCONST.TAX
in any way accrue against said City in consequence of the�ing Of this permit. i MECH.CONT. LIC.NO. MECH.
rorgL TOTAL
Bosture of Applicant/Contractor )ale
OFFICE COPY