9405 (2) APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICA ON vERMrt NumSER
BUILDING •• Lv,� APPLICATION & PERMIT
ADI RES
fT T BUILDING-ELECTRICAL-PLUMBING=MECHANICAL
9405
OWNER'S PLAN CHECK VALIDATION
.NAM OTY. ELECTRIC PERMIT FEE
.D OT7a s Mc� 41� '
CONTRACTORS
AME ��"" 2 }�I••�� OUTLETS-SWITCHES-RECEP 10.00/1.00 JtzL1^L L LIc.NAOS V r[„LIGHTINGFIXTURES 10.00/1.00 `b '
CONT
est °Rs ` ' APPLIANCES-RESIDENTIAL 4.00
ID PHONE(,QQ g-� PANELS 10.00 DATE OF APPLICATION _
ARCHITECT PLAN CHECK FEE P.C.NO.
DR ^ PANELS (OVER 200 AMP) 20.00
ENGINEE� LIC,
- -
c.rvG. SIGNS TRANS. .3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION -
A oREEss� �7
V /� �' •zIcrrEMP. METER OR POLE INS. 20.00 -
A - MOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICECHANGE - 20100
woo LICENSED CONTRACTORS DECLARATION TEMP..POLE
¢ v w I hereby affirm Ilmt I um licensed under pmvisione of Chapter 9 - ISSUANCE DATE
H < H (commencing with Section 7000)of Division 3 of the Business nnA BLDG. ELECT. PLG. MECH.
Professiq s C d• an license is in full fo �Iy e�y ❑ ❑ ❑ ❑
Oi v`�i �/1 Lice[ Con Number ZL LV r
,F.!Z'/�•t Dale _
Contractor � OC C�pBt LInO
st x N , - - City 1 BUILDING PERMIT
M
o d ° OWNER-BUILDERthatIaDECLARATION - MISC.- REFER TO OflD INFORMATION
X 3: I- I hereby affirm that I am exempt from the Cnntraclur•s License VALUATION $/FT.
u, v, Law forthe followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
QS,Q.O Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.'CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that - TOTAL {rN PERMIT TO
A•w m he is licensed pursuant to the provisions of the Comnclor's License
Law(Chapter 9(commencingwith Section 7000)ofDivision 3 of the �L�C.7
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; _ by any aPplicanl for a permit subjects the applicant In it civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).): -
❑ 1,us owner,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 docs not apply to an owner of
prgm,Ry who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5.00 BD.FT.FLOOR AREA TOTAL ACREAGE
orients re of intended
own employees,sale.pIf,h l(list ever,t h improve- ',
mems are throuhhis or offered nemployees,prILhos the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the BUILDING USE
owner- GAS-EA.SYSTEM-.OVER 4 (EA.) 2.00
builder will have the burden of Proving that he did not build or int- RES IND CON PB Om.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
0 I,as owner of the,properry,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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with it communing)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,BAP.C..loi this 7WATER HEATER W/VENT 6.00
reason
Owccr Date WATER SYSTEM - 5.00 ACC.OATE ALC.FILE NO.
WORK ERS•CONIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I herehy affirm Thal I ha crtiof consent to self-insure,
at nm
ZONING ENG.SITE NO.
or A certificate of Worke Co ar rane , r'a c ified
copy thereof($ c. N
Policy Nnk_L h _� C
Q / 01Certilted cop is here furnisl
Z 2 ❑ CeH ified c y is fe ith lh city i on division. - FIRE SPR INK ENERGY T-Z4
Applicant MISC.- _ REFER TO ORD. Y N� v N�
~ern PERMIT ISSUANCE 10.00
= CIiRT'I CA' FFXIiMPTI -ROM WORKERS' FLOOD ZONE A.L.U.C.
W � - PIFEXF NSURANf.G PLG.CONTR. LIC.NO.' PLG.
CL Z (This recti need nut be completed if the Pernlil is for one TOTAL - V❑ N -V O No
hundred dollars($100)or less.)
.U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
W F mit is issuede 1 shall a orke ' any person in any manner so is to'
O w become subject to the Workers'Compensation Laws ol'California.
IL Date ' Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
.} W NOTIC17 TO APPLICANT: If,after making this Certificate n1'
Ex-emption,you should become subject to the Workers'Compensal ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE "
U such provisions or this permit Shull be deemed revoked, AIR HANDLING UNIT(TO 10=CF.M.) . 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.P.M.) 6.00 SEISMIC FEE
I hereby afflrnr•rhal there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permii is issued(Sec. - MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 CO
Lender's Address ELECTRIC •��
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
i ormation is correct, 1 agree to comply with all city and county n PLUMBING
ordinances and state laws relating to building conslruction,'and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize re sentatives of city Ito enter upon the BOILER-COMP (Over l00,000BTU)SEE FEE SCH. MECHANICAL
C6 uoove-meniioned op rty fori tion TV
(We) u • ' c ify and k ep r.less the City of MISC.- REFER TO ORD.
Cupertino sr abilitie udgmenrs - and expenses which CONST.TAX
PERMIT ISSUANCE 10.00
may in y w Seem ainst sale in consequence of the
gamin of Ont mit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Siinto ol'Applleam/ actor . Date -
OFFICE COPY