8891 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATION PERMIT NUMBER
BNIL ING APPLICATION & PERMIT
AOOR Ff
$ EN r( 4^) BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8
OWNER' PLAN CHECK VALIDATION
-� NAME DTY. ELECTRIC PERMIT FEE
AJ .6,e fou PHONIArms-arpo
' Nome Acro/ns a UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRE � a ' PPLIANCES-RESIDENTIAL 4.00
e &J
PRONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER pn
uc.No. SIGNS TRANS. 3,00 P+•N
ARENG. PERMITqVALIDATION
ADDRESS
Ess SPECIAL CIRCUIT 5.00 1�t'j
ZIP EMP.METER OR POLE INS. 20.00 Aub 7_ U
APPLE ANTS Ts MOTORS SEE FEE SCH. Y1
SERVICE CHANGE 20.00 C1A7 U n!1 0'V
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 AUG
< u I hereby affirm that I am ut
licensed mer provisions of Chapter 9 2
2 w ISSUANCE DATE
so E2 (commencing with Section 7000)of Division 3 of the Business and
m i Professions Code, d my license is in full fore ejfPS� BLDG. ELECT.(1 PLG. MECH.
Zo i- o License Class Lic.NumM1er a, __ - - IVY ofl �p+�l"'1
L r Da[c_y�.�-_�j_�__Contractor LLJJ
Be x 4 ' (7 _ T BUILDING PERMIT
Be ¢ w a OWNER-BUILDER DECLARATION '
° ,` MISC.- REFER TO ORD •INFORMATION
xu ; I hereby affirm ing r I am exempt farm the Contractor's License
¢O ¢ Law for the following reason.(Sea 7031.5,Business anJ Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00 ��
mj Code:Any coo npair any structure permlltoconsuance,alsr,
tci a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.__N_0____7,LEC.
o ¢ requires lire applicant for Such Permit to file a signed statement that OTAL
n w m m he is licensed pursuant to the provisions of the Contractor's License n�PERM!T TO
a z a Law(Chapter 9(commencing with Section 7000)of Division 3ofthe v1 4
4 o Business and Professions Code)or that he is exempt therefrom and OTY. .PLUMBING PERMIT FEE
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 toa civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500E):
O L 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. 5.00
Code:The Contractor's License Law docs not apply to un owner of
property who builds or improves thereon,and who dots such work FIXTURES-PER TRAP 5.00 g0,PT.FLOOR AREA TOTAL ACREAGE
'f himself or through his own employees,provided that such improve-
mentsarenolintendedorofferedforsale.If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
.araa or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
JJ prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ' RES IND CON PR Omer
❑ 1,as owner of the property,an exclusively contracting with
licensed contractors to constructtheproject(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law docs 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 contracmr[s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&I'.C.for Ibis
rCJSOn WATER HEATER W/VENT 6.00
Owner _ Date WATER SYSTEM 5,00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby infirm that I have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance,or a certilled ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). r,�CM 0 N
Policy No. Company C6
U NTW5�
tified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Ztified Is fit I with the city inspection division.
p MISC.- REFER TO ORD. Y[] N� Y 0 N�
HPERMIT ISSUANCE 10.00
ISHCOMTIOFROMWORKERS' pL00o ZONE A.L.u.c.
f1 O COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. PLG. '
Z (This section need not be completed if the permit is for one TOTAL Y F] N� V N�
U O hundred dollars IS 100)orless.)
I certify that in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,I shall not employ any person in any manner so as Io
O w become subject to the Workers'Compensation Laws of California.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �3�
} CO NOTICE TO APPLICANT: If,after na king this Certificate of Ils-
I- Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10DWC.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
Leader's Name
Lender's Address - HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00
)` information is correct. I agree to comply with all city and county ff
PLUMBING
ordinances and state laws relating in building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
.t) hereby i
authorze representatives fthis city to enter upon th
above mentioned property for
purposes.
e BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
1 h
(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 CONST.TAX
may in any way accrue against said City in consequence of the 10.00 '
granting of IL p MECH.CONT. LIC.N0. MECH.
� _ S f^O TOTAL TOTAL
Signature of Apphcanl/Contactor Date •��
OFFICE COPY