9481 (2) APPLICANT TO FILL IN'INFORMATITHIN RED LINES - USE BALL POINT PEN ONLY ;
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
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noonoess O S 'enS C�(n. APPLICATION & PERMIT 9481
v Y'F O BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O xER'a PLAN CHECK VALIDATION
E OTY: ELECT�HIC PELT FEE
a�'i2- CAVO, PHONEZS7o74L
.�. NAMERAcroR's UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00 _
I
ADoR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
RESs '
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO ISIGNS TRANS. 100
moo'Foss ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDRESS
SERVICE CH 20.0 0 p'
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00ac
in w 1 hereby affirm that I Lim licensed under provisions of Chapter 9 A ISSUANCE DATE
y< w (commencing with Section 7000)of Division 3 of the Business and G.BLDELECT. PLG. MECH.
r w z Professions Code,and my license is in full force and effect Z 6 ❑ ❑ ❑
O 0 m W License Class m gj
Lic.Nuber
z.r Date Contractor ch e -
F
a y BUILDING PERMIT ,
M G, o U OWNER-BUILDFR DECLARATIONa: 0 - -
X ; w 1 hereby affirm that I am exempt from the Contractor's License MISC.- - RE R TO ORD INFORMATION
r u o j Law for the following reason.(Sec.7031.5,Business and Professions ,PERMIT ISSUANCE 10.00 _ VALUATION S/FT.
Code:Any city orcounty which requires a permit to construct,alter,, U
rt Q 0 improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires 1hC upplicard for such permit t0 file a signed Statement that TOTAL
a w$ he is licensed pursuant to the provisions of the Contractor's License PERMIT TOGG.G�7
F 2 a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
g i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
w E$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant loacivil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001.)
❑ I,as owngr 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 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 improve-
-1 ments are not intended or offered forsale.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-EA.SYSTEM-OVER 4 (EA.) 2.00
.Builder will have the burden of proving that hedld nor build or im- BUILDING USE
prove.for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON pe Omar
RES.
❑ 1,as owner of the property,am exclusively contracting with 0
El
licensed contractors to construct the project(Sec. 7044,limners 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 contmctons)licensed pursuant to
tSEWER-SANITARY-STORM EA.2001t
he Contractor's License Law. /10.00 TRACT NO. PARCEL NO.
❑ason lam exe under Se . ,B.&P.0 for this WATER HEATER W/VENT 6.00
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK FOMPENSATION DECLARATION - WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent W self-insure,
or a certificate of Workers'CompensationInsurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L
Policy No.-Company
O ❑ Certified copy is hereby famished' FIRE SPRINK ENERGY T-Z4
Z 2 ❑ Certified copy is filed with the city inspection division. MISC. REFER TO ORD.O Applicant Y N� I Y ❑ NE]
CC rn PERMIT ISSUANCE 10.00
LU - CERTIFICATE E SAEXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPO[ be completed
INSd RA the PLG.CONTR. LIC.NO. PLG.CL ❑ ❑ ❑ ❑
Z (This dollars need mol be completed if the permit is for one TOTAL V N Y N
' hundred dollars IS IOOI or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 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.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE. TO APPLICANT: IE after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE - 5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
3 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PEDC.F.M.) 6.00 SEISMIC FEE
1 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.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G U N IT(OVER 100,000 B.T.U.)9.50 jQ
Lender's Address - ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with"'city and comely PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.Or100,0008.T.U.) 6.00
+ hereby aoth.rue representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
ab.,e mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
ay in any way accrue against said City in consequence of the
Ming of this permit MECH.CONT. LIC.NO. MECH.
ac '1 TOTAL TOTAL
- "ata fApphcan[ ontre or I Da e
OFFICE COPY