C 9207 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I OENTI FICATION PERMIT NUMBER
BUILDING �,� I APPLICATION & PERMIT
1•\ A7 Ess d
- � , .5AL� n� BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 207
OWNER'5 g PLANC CK VALIDATION
""M�y� "174WWk7w OTY. ELECTRIC PERMITa FEE
Py-) • 45�J PHONE
/ NAME CONTRACTORS
CONT UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1,00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
AGGRESS j]
PHONE Q PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on 6C5PANELS (OVER 200 AMPI 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS ��J/ /y� SPECIAL CIRCUIT 5.00
d /V oA145- zip&7TEMP. METER OR POLE INS. 20.00
AP ucnrvrs
RICAN
MOTORS SEE FEE SCH.
A c y
5// �l�l�`'d� // • SERVICE CHANGE 20,00
o 0LICENSED CONTRACTORS DECLARATION TEMP.POLE 30
f
W.W I hereby alfum that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
r D i Professions Code nVmy license is in full for �qA
o 0=W License Class Lm.Number ,_ El El El
F m H J Dalc�— �E? Contraclor�6r-:�,G��/j��
a Y -+ BU DING PERMIT
a o n U
OWNER-BUILDER DECLARATION1 FORMATION
w ; LL 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
IeO ¢ Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 0 VALUATION $/FT.
Code:Any city Or county which requiresa permit to construct,alter, ' -
r ELEC.CONTR. LIC.NO.
¢ ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC. �f
yO LL requires the applicant for such permit to file a signed statement that TOTAL (� PERMIT TO
w $ he is licensed pursuant to the provisions nl the Contractor's License
r 2 i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
E z o Business and Professions Code)of that Ise is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant to a Civil penalty ALTER-DRAIN -WATER IEA.) 5,00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not CC.GROUP I RES.UIMS
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 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such impfove-
menlsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4OUT1_ETS 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 build - . . .
Or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ I,as owner of(lie property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors m construct file project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues 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 contractors)licensed pursuant to
the Contractor's Licensc Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
C lam exensptundcr Scc. ,B.&P.C.mrthis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORT:ERS'COMPENSATION DE:CLARA'FION WA TER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent or
certified ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copyN..,f(Sec.3800,1. C).
Policy
I'nlicY No.QQ1./11/1CompxnY—�/ 1 /•'
❑ Certified copy is hereby furnieleegl. FIRE SPRINK ENERGY T-24
Z ❑ Certife o y is fled w' e city AR"ection division. MISC- REFER TO ORD.
Q APPIiCu — Y ❑ N❑ Y❑ N❑
~ ATE
va
LU
EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W � COMPENSATION
PERMIT ISSUANCE 10.00 PIiNSAT10N INSURANCIi PLG.CONTR. LIC.NO, PLG.
CL 0 CI lux section need not be completed if the permit is for one TOTAL Y❑ N[:] Y ❑ N❑
D Z hundred dollars(SIO0)or less.)
V O I certify that in the performance of the work for which this Per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F 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.
a Date 'Applicant BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Fx- ALTER OR ADD TO MECH. 5.00
Z ensption,you should become subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
V such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 1Q000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A000.RM.) 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 n
Lender's Name HEATING 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 correct I agree to comply with all City and county PLUMBING
ordinances and slate laws relating IO building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of [his city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100.000 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'
Amay ny way accrue 'nst said City in consequence of the g f this Permit. ( MECH.CONT. LIC.NO. MECH.
• TOTALTOTALn=e
ofA plican/ nnlmctor Data
OFFICE COPY
1