09739 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION . PERMIT NUMBER
Sun LDING APPLICATION & PERMIT 09739
ADDRESS
9 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER' PLAN CHECK VALIDATION
"AME DTY. ELECTRIC PERMIT FEE
• i/
PHONE
N 3 - Po1
RA TOR's
AMEUTLETS-SWITCHES-RECEP 10.00/1.00
e�H)Lf uc.NO /,l S LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
'
ADDRESS
77.2,,/1-4Sao APPLIANCES-RESIDENTIAL 4.00
A
O% ST 0 PANELS 10.00 DATE OF APPLICATION
ogcHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE PC.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP FEMP.METER OR POLE INS. 20.00
•
APD
DDRESS MOTORS SEE FEE SCH. n
145�A Al S'/ '54-& SERVICE CHANGE 20.00
wa o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< it. I hereby affirm that I am licensed under provisions of Chapter 9
yam (commencing with Section 7000)of Division 3 0(the Business and ISSUANCE DATE
r y z Professions Colic, Edd n license is in full force an ell ty BLDG. ELECT. PLG. MECH.
o 0 w o License Class =.1.G__Lie.NumberEl El El
Dale 'Sr-oll —64� Contractor
Qiff
y E J
¢ ¢w a OWNER-BUILDER DECLARATION BUILDING PERMIT
o A INFORMATION
wg LL 1- 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
r LL O to Law for the following reason.(Sec.7031.5,Bramessand Professions PERMIT ISSUANCE 10.00 VALUATION §/FT.
Code,Any city or county which requires n permit to conal nmL alter,
a ¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
IN
S o Ic requires the applicant for such permit to file a signed statement that TOTAL
w m he is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
r Z r Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe �LO
a Business and Professions Code)or that he is exempt therefrom and DTV- PLUMBING PERMIT, FEE
sio
¢ P- $ the basis for the alleged exemption.Any violation otooSection malty STORIES TYPE CONSTR.
by any applicant fora imolueubjecrs the 5000.)applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(my employe
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 r0 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered (or 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 re through his own employees,pnwi led that such improve-
menlsarenotimmndedortiN'credforee safe.III that sthe building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
or improvemmnt is sold within one year of&RIpletion,the owner-
! builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Prove for purpose of sale J, / RES IND CON P8 On.,
I,as owner of the property,aitfexclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct Bee project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'The Contra (or's License Law docs not apply
to an owner of property who
h Ids or inpiroves thereon,mid who LAWN SPRINKLERS- VER 5(EA.) 1.00 '
contracts for such projects wills a contractons)licensed pursuant to SEWE ANITAR S ORM EA.200tt/10.00
the Contractor's License Laiyy� {1 TRACT NO. PARCEL NO.
❑ lam exempt under fc.
teaser ,B.&P.C.for this WATER HEATER W/VENT 6.00
Owner
Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKF- $'COMPENSATION DECLARATION WATER TREATING 5.00
1 hereby at that I have u certificate of consent to self-insure,
0r a certifila a o¢f,3Workers'Compensation Insurance,or a certified at; ZONING ENG.SITE NO.
copy thereof TO, NdUr00eW�`Po rgSmyL.bC.)./LeA 1lf/S GD
—
O Certified copy isI byf nisltttl' Airin FIRE SPANK ENERGY T-24
Z Z Certifi d o�y jc 111 ids the ty jnspeciion division
O Applic.i �6�7A ���a. �Ly. MISC.- 1 TO ORD. Y ❑ N❑ Y ❑ N❑
� N Cl IFICATI:01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-0011e-976 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLO.CONTR. LIC.NO, 7y PLG. q
•� Z (This section need'not,be completed if the permit is (or one D O L ✓�/ TOTAL •p�•�D Y[3N❑ Y C] N❑
hundred dollars($100)or less.) -
O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY. : .
LL F mit is issued,1 shall not employ any pers(n in any manner so as to
O W become subject to the Workers'Comoensa ion Laws of California.
Date Applicant_ ALTER OR ADD TO MECH. 5.00 BUILDING
} tail NOTIC17 TO APPLICANT: If,after m' ing this Certificate of Ex-
? emotion,you should become subject the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, yo must forthwith comply with FEE
U such provisions or this permit shall a deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION ENDINGAGENCY AIR HANDLING UNIT(OVER 10,O❑OGEM.) 6.00 SEISMIC FEE
I hereby affirm that there s a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the wor for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name-
pan
ame H EATI NG 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 (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING q
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 9
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP (Ove,1OD000 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 said City in consequence of the
granting of 11 is permit. MECH.CONT. LIC.NO. MECH.
tf( TOTAL
are of Applicant/C< actor
to Date TOTAL '
OFFICE COPY