9179 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
;BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
•� ROOILOINr, APPLICATION & PERMIT 9179
ADREaS2_(Z67 SrMN445
BUI LDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
PLAN CHECK VALIDATION
NAM` TY. ELECTRIC PERMIT FEE
slew Tom✓ m)
CONTRACTORS - UTLETS-SWITCHES-RECEP 10.00/1.00
uC.No.� 76kf LIGHTING FIXTURES 10.00/1.00 '
_ CON ACTOR'S APPLIANCES-RESIDENTIAL 4.00
DR 5 C
• ,/� • PANELS
AO10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 '
ENG WEER yy
3 uc.NoG",7 SIGNS TRANS. ' 3.00
LAPPL
R,ORE PERMIT VALIDATION
REss SPECIAL CIRCUIT 5.00
EMP. METER OR POLE INS. 20.00
.FSSA - MOTORS SEE FEE SCH.
RESS +S•f. �� SERVICE CHANGE 20.00 p
o o LICIiNSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /
< u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commmencirt with Section 7000)of Division 3 of the Business and
a N g BLDG. ELECT. PLG. MECH.
H o. Professions Co d my license is in full for- ❑ ❑
Z O rh,- Livens Class Lic.Number
9 m 5 w Dale .ems �!
Contractor - ��
H _ -
a r F -+ BUILDING PERMIT
¢ 0 i u OWNER-BUILDER RB UILDGR DECLARATION I RMATION
'x 3.0u. I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VWUDA
71 Col u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 S/FT.
Code:Any city or ,wwtly which requires a permit to construct,alter, � r•�yyF\'
rtR Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. g•1/
wO¢ nneires the applicant for such permit to file a signed statement that ,TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractors License
rZQ Law(Chapter 9(commencing with Seel ion 7000)of Divislon3ol'the
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I=- the basis for the alleged exemption.Any violationo(Section 7031.5 1 STORIES TYPE CONSTR.
n ;$ by any applicant fora permit subjects the upplicant to a civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(S500y):
❑ I,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 st rueturc 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 huilds or improves thereon,and who(toes such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.Provided that such improve- i.
hients mself a through
ot oro employer,provided
however,thatsuhebuilding 'GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or on.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ower
13I,as owner of(lie property,am exclusively contracting with ❑' ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law does not apply
lo an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
I mels for such projects with a contraclor(s)licensed pursuant to SEWER-SANITAR V-STORM EA.200D/1 0.00 the Contractors License Law. TRACT NO. PARCEL NO.
- ❑ l net exempt muter Sec. ,114P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have'a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
copy thereof(See.
Policy ere Copper
_
O ❑ Certified py is It y It ted FIRESPRINK ENERGY T 24
Z 2 ❑ Cer"rf copy �f�IejL ne 'upec(ion division. MISC.- REFER TO ORD.
F O Applicant Q�p4�LM _,�!y(� �'Y❑ N❑ Y ❑ N❑
FF 17. // PERMIT ISSUANCE 10.00
- CERTIFICA'I'G OF E%EMP ON PROM WORKERS' FLOOD ZONE A.L.u.G.
LU - COMPFNSATIO INSURANC17 PLG.CONTR. LIC.NO. PLG.
a_ Z( This section need.not be conopleted if Elthe permit is for one TOTAL - Y❑ N❑ Y NO
hundred dollars(5100).,less.
V O 1 certify that in one performance of elm 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
Q w become subject to the Workers'Compensation Laws of California.
y Daic Applicant ALTER OR ADD TO MECH. 5.00 'BUILDING '���
} W NOTICE TO APPLICANT': If,after making this Certificate of E.-
FZ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the-Labor Code, you must forthwith comply with FEE
U such pmvisiorta or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONS'fRUCPION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE s>Sa
I hereby uffinm (hut there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
(lie performance
ce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
Lender's Nance HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that(he above VENTILATION FAN (SINGLE) 4.00 .
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby zuthorize'represenla(ives of this city to enter upon (he BOILER-COMP (Over 100,000RTU)SEE FEESCH. MECHANICAL
above.nantioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino against lin bilioes,ju nen is costa and expenses which CONST.TAX
may in any way e a sai icy in cons uese f the PERMIT ISSUANCE 10,00
gfanti fihis it MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL'
nature of pp man Contr for
Date
'OFFICE COPY, -