09652 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT,IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
.•i A11W ke, 1 "y BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 0.9652
O�WN1 ipr(F/� v-T,�p(1,�,,LM,,1,1 PLAN CHECK VALIDATION
I11 �su/cat ` Ou'R 1 O OTY. ELECTRIC PERMIT FEE
PMONE
CGNTR
NAME 10Y1h I' 7()11C'If )Unuigq dillOFOUTLETS-SWITCHES-RECEP • 10.00/1.00
1 e4�hd�F► Y)(, ' uc.rvo. I�V� LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADD ss yy���� ('1F, T1_�I PPLIANCES-RESIDENTIAL 4,00
a- Ir'v" �+I.ll� PHONE 5d -X4:s PANELS - - 10.00
DATE OF APPLICATION
OgcwrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER '
uc.NO. SIGNS TRANS. 3.00
Afl CN.OR ENG.
ADDRESS 'SPECIAL CIRCUIT 5.00 ,PErlpllry dATION
Zlp EMP.METER OR POLE INS. -20.00 1�'/� �.IJ
APPLICANT'$ '
ADDRESS MOTORS SEE FEE SCH. CCn n 1961SERVICECHANGE 20.00 DLI' J
00 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,City H�ppBftIf1O
a is v I Iterehy ul'I irm that I am licensed under provisions of Chapter 9
City
i w
H¢ h (commencing with Sermon 700of Division 3 oldBusiness and ISSUANCE DATE
BLDG. ELECT. PLG MECH.
r T z Professions Code,and my licensee is in(aefll force and effect. ❑
2 O -, License Class Lic.Number -
O w f w Datc Contractor
am IS -' OWNER-BUILDER _ -
IS 2 w a DECLARATION BUILDING PERMIT/
M ° MISC.- REFER TO ORD INFORMATION'
g LL r I herehy affirm that I um exempt from Ilse Contractor's License.
w LL O a Law for the following reason.(Sec.7031.5 Business and Professions - VALUATION $/FT,
- PERMIT ISSUANCE
M � � Code:Any mol or county whiny structure,
lerminoconsnallc alter, 10.00
S, Ii ¢ improve,demolish,or repair any strut are,Prim In its issuance,also ELEC.CONTR. ' LIC.NO. ELEC.
- °u requires the applicant for such permit to file a signed statement Ilial TOTAL
e. w w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
z a Law(Chapter 9(commencing with Section 7000)Of Division 3 or the a
FE O Business and Profession's Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
'ter c, the basis for the alleged exemption.Any violation of Section 7031.5 STORIES. TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(§500).):
❑ I,as owner Of the,pruperty,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the aTRatt ure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00 0_6Code:.The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
Ininself or through his own employees,provided(hat such improve.
mems are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
or improvement is sold within one year of completion,Ote owner-
builder will have the burden of proving that he did not build.,an- GAS-EA.SYSTEM-OVER 4(EA.) - 2.00 cul IN E ,
prove for purpose ofsaleJ' INDUSTRIAL WASTE INTER. 30.00 RCS IND O PB Omer
O 1,as owner of the property,to, exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAW N'$PRINKLERS-i INC 5 V.B. 6.00 pSSEs R CEL NO.
and Professions Code:The Contractor's License Law does not apply
to un.owner of property who.1hords or impmdes fiction,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts forsuch projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ;B.& P.C.for mus
anon WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKF:RS'COM P17NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or it certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thergpjl8 a .C.). I
Policy Ni ny k/0 • n.
Q L7 Certified co s erCM1 onished.
Z Z Ccrtin p s f with-t nspedion Division. FIRE SPRINK ENERGYTR4
� p Ap-plicam MISC.- 'REFER TO ORO: Y � No Y0 N�
� y Cl: TE 017 EXEMPTION FROM WORK F RS' PERMIT ISSUANCE 10.00 •UD FLOOD ZONE A.L.U.C.
'LU COMPENSATION INSURANCIi ✓ 0 L p_ 1 PLG. . �qq Co
CL O (This Section need not be completed if the permit is for one ✓fT �� TOTAL ra4J I Co Y❑ N� V[:] NC]
Z) Z hundred dollars IS 100)or less.)
U O 1 ecatity that in the red'..Manes of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued, I shall not employ any person in any mannerso as to
become subject to the Workers'Compensation Laws of GJifornia. -
y Date Applicant - BUILDING
} N NOTIC17 TO APPLICANT: If,after making this Certificate of Ex ALTER OR ADD TO MECH. 5.00
� Z emption,you should become subject to the Workers'Conipensution APPLIANCE 5.00 PLAN CHECK s'
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit sha11 he themed revoked. AIR HANDLING UNIT(TO 10AWC.F.M.) 4.00
CONSTRUCTION[.ENDING AGENCY - AIR HANDLING UNIT(OVER IO)OODC.EM.) 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
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 q
information is correct. 1 agree to comply with all city and county PLUMB _ IA
oNinBOILER 13 H.P.Or 100,000 B.T.U.) 6.00 INGances and state laws relating to building construction, and oLll
hereby authorizeeproperty lot ves
of this city to enter upon the BOILER-COMP(❑ver 100,000 BTU)SEE FEE SCH. MECHANICAL �
hereby
tioproperty I'or inspection of
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- _ REFER TO ORD.
Cupertino against liabilities, gmenls, costs and expenses which 'PERMIT ISSUANCE 10.00 Q CONST.TAX
may in any a ' cme ainst said in cons uence of the ' `
grantln unit' 1'/ Q� �r��ppECH.CONT. LIC NO MECH. . /�
14,"J TT�1QYtQn Ar (b-J,,,m ,� d//l��� r�Pp OTAL l� TOTAL
S' afu ofA icn on ac Llafe, N.0 I�fCtifYYY1 InC. _r�`-V IL�if I
., OFFICE COPY