09790 (2)' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
-)p BUILDING APPLICATION & PERMIT /� /�
ADDRESS O J lJ Lj O
-SeN^ ol. UILOING - ELECTRICAL-PLUMBING -MECHANICAL J
owry
N �'' p PLAN CHECK VALIDATION
O�O 'QplVe PRONE DTV' ELECTRIC PERMIT FEE
CONTRACTORS r UTLETS-SWITCHES-RECEP 10.00/1.00
�L 60&1 AAA LIC.N31Z�/� LIGHTING FIXTURES 10.00/1.00
CONTRACTORS /�a�x11_ ////II,,^^ PPLIANCES-RESIDENTIAL 4.00
AD /o IVC.M IrJ /W,04NE ^(l� �O PANELS 10.00 DATE Of APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ANCH
ADDRESS OENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE.INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS IK- lig SEr'-
RVICECHANGE 20.00 '1
oo LICENSED CON TRACTORS DECLARAT ION TEMP.POLE 30.00
a u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSU/N?CATE
H Q vw (commencing with Section 7000)of Division 3 of the Busin d BLDG. ELEC . PLG. MECH.
r y z Professions o a license is in full fO a
o z m o License la. Lia Number ❑ ElF m J Dalc Contractor
QW I
>< BUILDING PERMIT .
o d U OWNER-BUILDER DECLARATION - INFORMATION
X g LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter,
S2¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC CONTR. LIC.NO. ELEC.
rL w m LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)0r that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
I- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES VPE CONSTR.
n3 by any applicant for a permit subjects the applicant In a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
Of not more than five hundred dollars(5500).):
❑ 1,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 ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'file 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 g0.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such in.prove-
mentsarenot 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(EA) 200
builder will have the burden of proving that he did not bu - . - . .
ild or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 13 D El El C1
• licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Low does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a comractoAs)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO,
❑ l not exempt under Sec, ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5,00 ACC.DATE ALC.FILE NO.
WORKERS'COMPENSATIONDECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
-� copy thereof(Sec.3800,Lab.C.I
Policy No.-CompanyV(.t��
❑ Certified cop is hemb furpishesi' FIRE SPRINK ENERGY T-24
Z �Y Certified Its f with tl it inspec 'on division. MISC.- REFER TO ORD.
F A $cant V N V NEI
� y CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CIL
(This Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y 1:1 NEI
D Z hundred dollars(S 100)or less.)
U 0 1 certify that'in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
L F- mit is issued,I shall not employ any person in any manner s0 as to
U
O become subject to the Workers'Compensation Laws of California.
y Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ W NOTICE 10 APPLICANI's If,after making this Certificate of Ex-
F, Z emption,you should become subject to the Workers'Compensation APPLIANCEL 5A0 PLAN CHECK
provisions of the Labor Code, you most fofthwilh comply with FEE
C„J such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F. 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNI 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD( DUCT) 5.00
the performance of the work for which-this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 8.00 MICROFILM
Lender's Name HEATING UNIT 00,000 B.T.U.)9,50
Lender's Address - ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information .coracoagree to comply with all city and county PLUMBING
ordinances and state laws
relating to building construction, and BOILER-COMP(3 H.P.or100,000 B.T.U.) 6.00
hereby authorize representatives Of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL Tp
above-mentioned property for inspection purposes. .7 L
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino t liabilities,judgments, costs and expenses which
I in PERMIT ISSUANCE 10.00 r CONST.TAX
ay y y ac against said City in conseyue e of the .(J
grant O is per MECH.CONT. LIC NO. MECH.
c fA OTAL TOTAL
.ignalurc of Applicant/ContrnetO ate J
OFFICE COPY