9256 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
�! pmL➢ING BUILDING PROJECT I DENTI FICA710N APPLICATION & PERMIT
v aooREs � Y3� 9256
ILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME �n•�-�x/ OTY. ELECTRIC PERMIT FEE
SlLVL£Qg1Jp OFF/CCG v"orve 'C�
NOMEaacroRs� UTLETS-SWITCHES-RECEP 10.00/1.00
o /M wCo LIc.No. 6 LIGHTING FIXTURES 10.00/1.00
.� ADDRESSTORS PPLIANCES-RESIDENTIAL 4.00
CARR �To P�•/Tt�sC"E 3�7- PANELS 10.00
PATE OF APPLICATION
RCNITECT
oR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
NGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,
oo Ess ENc. SPECIAL CIRCUIT 5,60 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ,f
APPLICANT'S MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 20.00 q p
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a wo u I hereby affirm that I am licensed under provisionsof Chapter 9
i w ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
r y'^ Professions Co Oan by license is in lull fore f L ❑ ❑ ❑
0 o m LicensesG s Lie.Number
4 z- ow batt Contractor
Q IS M J
E 0 w ¢ OWNER BUILDER DECLARATION BUILDING PERMIT
E
;LL m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
u O v, Law for the following reason.(Sec 7031.5,Businessaad Professions VALUATION $/FT.
I- - J PERMIT ISSUANCE 10.00
I m i Cade:Any city or county which requires permit to construct,alter,
u,Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
sa O u requires the applicant for such permit to file a signed statement that TOTAL
A w m he is licensed PERMIT TO
pursuant ing provisions the ).f Division License �L 01-e,4 /�^
rza Law(ChapterProfessions
Code)or Section is exemfttheron3ofthe lT
E r c Business for
Professions Code)or that he is exempt core r70 and QTY. PLUMBING PERMIT FEE
¢ H$ the basis for[an alleged exemption.Any violation t taction malty STORIES TYPE CONSTR.
di by any applicant fora permit subjects $500).the licanttoacivilp¢nahy ALTER-DRAIN St VENT-WATER IEA.) 5.00
of not more than five hundred dollars(E500)J:
❑ 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 OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. Fr99
Code:The Contractor's License Law does riot: to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP rG:(1O --• 50.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees.provided that such improve-
meats are not intended cooffivord for sale.If,however,the building GAS EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessW-F
KLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:1'he Contractor's License Law does Rol apply
S_GQ
to an owner of property who builds or improves thereon,and whoKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractots)licensed pursuant to
the Contractor's License Law. TARY-STORM EA.200ft/•14:00 - TRACT No. PARCEL NO.
rca❑nlam exempt under Sec. ,B.&BC.I'or thisTER --6.00Owner Date EMACC.OATE ACC.FILE NO.
WORKIiRS'COh1PF.NSA'fION DECLARATION INGfE Ip 5.001 hereby affirm that I have u certificate of consent to self-insure,or a certificate of Workeri CompensationInsurance,or a certifiedZONINGENG.SITE NO.
copy thereof(Sec.3500.Lab.C.)s7 flTF FUN 17 ) OC CU BlfPolicy No. Company J /� )
❑ Certificd co 1 re'y famished.
Z ❑ Certified i er led wi
O division. FIRE SPR INK ENERGY L74
I-- 0 Applicant MISC.- REFER TO ORD, v E] N v N�
N CE:RTI F I CATE O I'FXEM PT ION 17 ROM WOR U'RS PERMIT ISSUANCE -*-eo FLOOD ZONE A.L.U.C.
Q. COMPENSATION INSURANCE, PLG.CONTR. LIC.NO. PLG.
Q. ❑ (This socliri. need not be completed if the permit is for one TOTAL Y 00 N� Y N�
O hundred dollars(S 100)ar I,,S)
I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to FEE
O L) become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
)- _ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
C7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONSTRUCTION LEND1NC AGENCY AIR HANDLING UNIT(OVER 10=C.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.
3097,Civ.C.). HEATING UNIT(TO 100,000B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATINGUNIT(OVER100,000B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n estate[.1 laws
to comply with all city and county PLUMBING
ordinances end stale laws relating m 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. BOILER-COMP(Ova,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
may in at way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
gm this p¢rmiL MECH.CONT. LIC.NO. MECH.
TOTAL
/` Slgna(urcofAOphc:uh[/Contractor � pat �)- TOTAL
OFFICE COPY