09767 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT0'9767
'A DRE55 '
_ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL•
P's PLAN CHECK VALIDATION
•
NAE QTY. ELECTRIC PERMIT" FEE
ME //��o. 1 WrL PHONE
NAMEPAcroRs OUTLETS-SWITCHES-R ECEP
�n0 Agecly-sl%ir.--. 6 LIGHTING FIXTURES 4499PM0
f-ONTR CTO R'S
A�D/ORE s r
/w2 F, ; 1Jlel ONE PANELS 10.00
GATE OF APPLICATION
OgcnrtecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc,No. SIGNS TRANS. 3.00
AHCH.OR ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
DDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT
PPLICA Ts7/,. .�• / MOTORS 'aEtFr�-erFl
y„ ro.co . i�acn
SERVICECHANGE 20.00
Ve 0 o LICVINSEDCONTRACTORS DECLARATION TEMP.POLE 30.00
¢ o u I hereby affirm that I urn licensed under provisions of Chapter 9 ,00 ISSUANCE DATE
a
w< a (commencing with Section 7000)of Division 3 of the sur, BLDG. ELECT. PLG. MECH.
0 y Z Professions Code, nd my license is in full force and effect ne $�E r S� SWAP ❑ ❑ ❑
z O w- Liconsc loss ��Lic.Nwnber_ l-r+3- a Vj. 7„raP�
O Z r w Datc - -�1-?C Conlructor_ Ej /....n �7 k /mer �Qi��
BLAILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
U ' INFORMATION
w ; °' I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
a_o a Law for the following reason.(Sec.7031.$,Rusinessand Professions VALUATION
H - st PERMIT ISSUANCE 10.00 �r00
tato Code:Any city or county which requires a permit to construct.alter,
p p a Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signed statement that + `J TOTAL
u w $ he is licensed pursuant to the provisions of the Contractor's License s 7 3 r O' C PERMIT TO
H r Law(Chapter 9(commencing with Section 1000)of Division 3 ofthe L �
so Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT . FEE:'
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toll civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five Imndred 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 st racture is not
intended or Offered for 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 $D.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such Prove-
men improvenotment
is old or within
onefor
year
If,however,t the o nc- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the harden of proving that he did not build or am'- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Oer,
❑ I,as owner of the property,am exclusively contracting with m❑ ❑ 0 � E]
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 Law 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 conlractoos)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,IL&P.C.for this WATER HEATER'W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that I have a certificate ofconsent to sel Glnsme,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L
Policy No. Company
, 0 ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T-24
z 2 �C Certific co y_s-filed with h city gspectinn division.
F O A plicanl n �.�.,rq¢_ MISC.- REFER TO ORD. Y [] N[3 Y E] No
C W CERTIFICA'1'F.OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y� NC] Y ❑' eN[3
U O hundred dollars($100)or less.)
I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
n Dxlc - Applicant BUILDING
} m NOTICE TO APPLICANT: IL after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
2 caption,you should become subject to the Workers,Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, ynu Rost forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANOLING UNIT(OVER 10=1 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,C1v.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 6.5 S'�
Lender's NarneAddress ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(Wei agree to save, indemnify and keep lmrmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
Py in any way accrue against said Cit in consequence of theing of thispennt, MECH.CONT. LIC.NO. r MECH.
TOTAL TOTALture of Applicant(Contracmr Dace �IJO
.. OFFICE COPY ,
_ 1