09693 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
nD,Lp,NG APPLICATION &PERMIT O
ADOREs� 2 / C2 .� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9693 a
OWNER'S l' - PLAN CHECK VALIDATION
�l NAME O U'S QTY. ELECTRIC PERMIT 4 FEE
PHONE
CONTRACTOR'S
/ NAME UTLETS-SWITCHES-RECEP .10.00/1,00
_ ! uc No. .0 LIGHTING FIXTURES 10,00/1.00 E
ArOR's
ADDRESS
- PPLIANCES-RESIDENTIAL 4.00
601, 00,1 ylz�- I' PHONE 71611 PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200'AMPI 20.00 PLAN CHECK FEE P.C.NO..
OR
ENGINEER .
LIC.NO. SIGNSTRANS. 3.00 `
ARCH,OR ENO r' $P.ECIAL CIRCUIT _ 5.06 PERMIT VALIDATION
ADDRESS
nv TEMP.METER OR POLE INS. 20.00
APPLICANT S - - MOTORS - SEE FEE SCH.
ADDRESS
'
SERVICE CHANGE- 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u C, I hereby affirm that I am licensed under provisions of(Chaptet 9 - ISSUANCE DATE
a¢ w (commencing with Section 7000)of Division J of the Business and BLDG. ELECT. PLG. MECH.
D z Professions Code,a d n1yy -ense u in full loq ` dH. - ❑ ❑ ❑
z 0 m - License Class Lia Numher
77
9 a, ° Dam Conlmctar
x s BUILDING PERMIT
5 a w u OWNER-BUILDER DECLARATION INFORMATION
oA ,=MISC,- REFER TO ORD
H I hereby affirm that Pum exempt from the Contractor's License VALUATION $/FT.
Fu0¢ Law for the following reason.(Sec.7031.5,Business Professions ,PERMIT ISSUANCE 10.00
Code:Any city or county which rerluires a permit to construct,alle,,
QQ ¢0
improve,demolish,orrepaii-mystructure,priorto'its'issuaace,also ELEGCONTR. LIC.NO. ELEC.
n
- °0 requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO -
w$ he is licensed pursuant to the provisions of theContractor's)ofi License
rzr Law(Chan Professions
Code)or Section is exempt
D theren3 of the
¢ a Business and Professions Code)or that he is exempt Schon 7031.5 PLUMBING PERMIT FEE
i,o the basis for the alleged exemption.Any violation ofSection 703 L$ STORIES TYPE CONSTR.
a. by any applicant for a permit subjects the applicanito a Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5,00
of not more than live hundred dollars 0500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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,AR EA,COND. 5.00
Professions,
Code:The Contractor's License Law does not apply to an owner o
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
A himself or through his own employees,provided that such Improve=
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the harden of proving that he did not build or int - . RES IN CON PB GO.,
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
..� I,as owner of the property,am exclusively contracting with
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 docs not apply ,
to an owner of properly wilt)builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to - SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO,
O I an exempt under Sec. 'i B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION
In
TREATING EQUIP. 5.00
I `
I hereby affirm that I hove u eurr f cafe ofconsent to sell'-insure, ,ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
1Copy there.f(Sec.3800,Lnh.C.). pU 14( L (�
Policy No. Company �- f
Q pp Cyyrtified copy is hereby furnished. FIRE SPRINK ENERGY T$4
Z LYCertified'ct) s tiled wi '�• ^ ^°^"' I' 'i
O ' Applicant =--I� MISC.- REFER TO ORD. 'Y ❑ N� Y ❑ N❑
1- rt) PERMIT ISSUANCE 10.00
Lu CERTIFICATE OF EXEMPTION N INS PROM WORKERS' FLOOD 20NE A.L.U.C.
W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. '
CL O .,'(This section neer] nal be completed if the permit is for o� TOTAL Y❑ N❑ Y❑ N❑
Z hundred dHILRS(SI00)or less.) � pe,^
CU 0 1 certify that in the performance of the work for which this per. QTY MECHANICALe PU f FEE FEE SUMMARY
LL E. mit is Main,1 shall not employ any person in any manner sn as to
O Dobecome subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f.--? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nost forthwith Comply with FEE
U such provisions or this permit shall be deemed revoked. - AIR HANDLING UNITOR4.00
CONSTRUCTION LENDING AGENCY ,/t AIR HANDLING UNIT(OVERIOJ"C.EM.) 6.00 SEISMIC FEE
I hereby affirm Ilia, 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 'ELECTRIC
Lender.'s Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
h formulion is correct. I agree to comply with all city-and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
' hereby authorize representatives inspection
this city es enter upon the 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL /6
above-mentioned properly for Inspection puity to.
(We) agree to save, indemnify and keep harmless'Ihe City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which - PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the '
granting of thj MECH.CONT. LIC.NO. MECH.
t - �� TOTAL /q UG
Signature of Applicant/Contractor /s+' TOTAL
OFFICE COPY