09695 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT 09695
BUILDING
ADDRESS G BUILDING-ELECTRICAL-PLUMBING-MECHANI
PLAN CHECK VALIDATION
OWNER'
/DTV. ELECTRIC PERMIT FEE
VJrf�� Orvr�'�/ ,
co r 9000TORS / UTLETS-SWITCHES-RECEP 10.00/1.00
:,)„T,,:,,'• / I LIGHTING FIXTURES 10.00/1.00
CONTRACTOR 5 APPLIANCES-RESIDENTIAL 4.00
AOOREs f�
RON (lj PANELS 10.00 OCHEOF APPLICATION
ARCITTECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR .00
ENGINEER SIGNS TRANS. 3 ---
LIC.NO, PERMIT VALIDATION
ancR,OR ENG. SPECIAL CIRCUIT 5.00
ADORE55
zlP EMP.METER OR POLE INS. 20.00
APPuc NJA_� MOTORS SEE FEE SCH.
ADDREB /1 -"���{J
_ SERVICE CHANGE 20.00
11 TEMP.POLE 30.00 L
wo O LICENSED CON'I'RACiORS OIL �i�❑p j)
a is w I hereby affirm that I am licensed under provisions of Chapter 9 n ELECT.
O LC��
H < (commenang wit Sec On 7000)of Division 3 of the Business and L1Y^ 0 ELECT. PLG. MECH.
H p i I'mfessions Coln cense is in full f Y �t1 (0,U 0r[:;]'
z o= - License CI Lic.Numb
o m w Date Contractor - BUILDING PERMIT
a In ;INFORMATION,
2 w u OWNER-BUILDER DECLARATION 0 ORD
K 0 A I- 1 hereby affirm that I am exempt from the Contractor's License IM ISE- _ LUATION $1FT.
Foo J Law for the following reason. 7031.5,business and Professions PERMIT ISSUANCE 10.00
Code:Any city or County whichrequlresapermll to Construct.allot. ELEC.CONTE. LIC.NO. ELEC. i 9Oti,� V
Q Q 0 improve,demolish,Of repair any stmelure.Pit.,to Its i"Dance,.ISO TOTgL CJ PERMIT TO
0 , requires the applicant]or such permit to file a signed statement that
n w $ he Is licensed Pursuant to the provisions of the Cao tracers License
F z> Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
e Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE STORIES vPE cO NBTR.
IS r D the basis for the alleged e.va ptki Any violation of Section 7031.5
p3 _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500)):
❑ 1,as owner of the property,Dr try ontpeyces 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 AREA,COND. 5.00
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF, `
Code:'fire Contractor's License Law does not apply to an owner nl
�. property who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.00 50.FT.FLOOR AREA TOTAL ACREAGE
x himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 l'
menu are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE 1
builder will have the burden of proving that he did not build or an- REB IND O PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑, ❑
❑ I,as owner of the properly,am exclusively contmeting with
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESS RCEL 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 IEA.) 1.00
contracts for a rejects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
the Cont' icense Law,
❑ 1 ex
for
Scc. ,B.&1'.C.far this WATER HEATER W/VENT 6.00
as
O cr Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 Imreby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
9"=!
of Workers'Compensation IBeuranm o u I'y/ FIRE BPRINK ENERGY T-Y4QPY is ere+ f noshed.z Zyi 1 rv➢ilyl •eWi i MISC.- REFER TO ORD. v ❑ N❑ Y ❑ N❑PO / / 7
PERMIT ISSUANCE 10.00 PLooO zorvE L.U.C.a.
� y CERTIFICATE OF Ii%EM1IITION FROM WORKERS' PLG.CONTR. Uro.NO. PLG. y❑ ry❑
UJ > COMPENSATION INSURANCE Y❑ N❑
d O TOTAL
('this section need not be complete) if the permit is 1'Or one
U 0 hundred fy thins(n the)pe less) FEE SUMMARY
U O I certify Bat in the performance of the work for which this per- QT,r � MECHANICAL PERMIT FEE -
F mit is issued strait not employ any person many manner so us to
O W become ect to the Workers'Compensation Laws of California. BUILDING ��
Date- Applicant ALTER OR ADD TO MECH. 5.00
>- 0. NOl'1 :TO APPLICANT': If,after making this Certificute of fix- 5 00 PLAN CHECK `` Z
r 2 emption,you should become subject to lire Workers'Compensation APPLIANCE FEE K
U suer provisions.,Wtsbpern iittdShut be deeyoo med invoked comply with ,AIR HANDLING UNIT(TO 1OJ000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C.F.M.) 6.00 SEISMIC FEE ,fU
I hereby affirm tit t there'is a construction lending agency far EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM
the performance he work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 p
3097,CIv.C.). /j
309JersN ne HEATING UNIT(OVER 100,000 B.T.U.)8.50 ELECTRIC
Le0-0
nder's Address
I certify Bel I have real this application and stare that the above VENTILATION FAN (SINGLE) 4.00 gMECHANICAL
infonnution is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city e enter upon the BOILER-COMP (Dverloo,000BTU)SEEFEESCH.I abovo-mentened propertyfar inspection purposes. REF ER TO ORD.(We) agree to save, indemnify and keep harmless the City of MISC.-
ud nnds, costs and ex noes whlel Cupertino ugu st liabilities,j 6 Pa PERMIT ISSUANCE 10.00crue against sWd ty in C nseenc MECN.LONT. L10.N0. TOTAL /
Sipatolrof App io' t/Contractor `Date
OFFICE COPY