09861 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
+ BUI LD1 NG PROJECT 1 DENTI FICATION _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT O n
ADDRESS `�'
2 BUILDING-'ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME PLAN CHECK VALIDATION .
• ON OTV. ELECTRIC PERMIT FEE
91,
ONTRACTORS
NAME p I UTLETS-SWITCHES-RECEP 10A0/1.00 J(7�
Com(-1!OG� I l uc.N¢CIb-o1-(tI I -73 LIGHTING FIXTURES 10.00/1.00
noo ESE rot's PPLIANCES-RESIDENTIAL 4.00
1- 6 ,6+ PHONE PANELS 10.00
OI J DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR - _ PANELS (OVER 200 AMP) 20.00
ENGINEER
LAC.No. ISIGNS TRANS. 3.00
ZRCH ADDRESS ENG. SPECIAL CIRCUIT ' sG r , 5.0014-,0 PERMIT VALIDgTION,
zIP EMP.METER OR POLE INS. 20.00
MOTORS ' SEE FEE SCH.
�U -n '��fT� SERVICE CHANGE 20.00 a
w o a LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00----.:
Q o u I hereby affirm that 1 int licensed under provisions of Chopter9
ISSUANCE DATE
y <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r z Professions Code,an , Iy license is in full,mre a td eIT 1.
o f=o License Class p m.Numb v 1
r m r J
Date l Contract.,
w _ OWNER-BUILDER DECLARATION BUILDING PERMIT
w0 u m I hereby affirm that I am exempt from the Conlracror's License MISC.- 7- +. REFER TO ORD INFORMATION
u o 4 Law for the following rcason,(Sec.7031.5,Businessland Professions VALUATION -$/FT.
- - PERMIT ISSUANCE 10.00 ��^^
� .4 2 Code:Any city or wumy which Tenures permit to construct,alteq I
O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC:N0. ELEC. - -
O M requires the applicant for such permit to file a signed statement that
n w m" he is licensed pursuant to the provisions of the Contractor's License lC 7 I TOTAL , - PERMIT TO
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe EL EG7
f 4 o Business and Professions Code)or that he is exempt therefrom and TY. PLUMBING PERMIT -FEE
ac s-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
,d ; � by any applicant ora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as CK F LOW PROTECT:DEVICE - 4.00 Occ.GROUP RES.UNITS
their Sale compensation,will do Ilse work,and dile Strtlnture is not
intended or offered'for sale (Sec. 7044, Business and Professions DR INS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXT RES-PER TRAP 5.00 sD.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve. .. ,
meats are not inter
ended or offered for sale.If,howev ,tire .
e building GAS-E SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion;the owner GAS-EA. VSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.); INDUSTRIA WASTE INTER. 30.00 - RES IND CON PB Omar
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ 0 ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPR IN ERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. t
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKL RS-OVER 5(EA.) 1.00 -
contracts for such projects with a contract.oto licensed pursuant to SEWER-SANITAR TORM EA200ft/10.00
the Contractor's License Law. . TRACT NO. PARCEL NO.
❑ [am exempt under Sec.,B.&P.C.for this
reason WATER HEATER,W/ NT 6.00
Owner Date WATER SYSTEM xxx 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER'TREATING EOU0l 5.00
I hereby affirm that I have a certificate of consent to SelGinsum,'or a certificate of W$orrkers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
Poilcylre,NrN+' S0 35LAom Pang'),(IIG
_'❑'//Certified copy is hereby furnished, FIRE SPRINK ENERGY T-24
Z'Z rC,rtificd�}��+y�Is� file�t1,,gqlib hy' �ity ns reef�+n division.
F O Applican;Hfied ' a 'F'l'/11' L_ MISC. REFER TOD. ' Y E] No ' Y NQ
N CERTIFICATEOF EXEMPTION FROM WORKERS' - PERMIT ISSUANCE -10.6Q, FLOODZONE A.L.U,C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC,NO, PLG,
OL. o (This section need not be completed if the permit is I'or one TOTAL Y❑ N V❑ N❑
Z hundred dollars($100)or less')
U
01 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
Ow' be come subject to the Workers'Compensation Laws of C.li(nmia.
y Date ApplicaBUILDINGnt ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation pP LIANCE' 5.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply Witt, _ FEE "
U' such'provisions or this permit shall be deemed Invoked, AI ANDLING UNIT(TO 10MCY.M.) 4,00
CONSTRUCTION LENDING AGENCY - AIRH DLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUS HOOD (WITH DUCT) 5.00
tiro performance ul'the work for which this per Is issued ISaa' Is
MICROFILM
3097,Civ.C.). HEATING U T(TO 100,0001 B.T.U.) 8.00 - -
Lender's Name
Lender's Address HEATING UNI VER 100,000 B.T.U.)9.50 ELECTRIC
I certify tlmt I have read this application andstate that the above VENTILATION FA (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-COMP(3 H.P.O 00,000 B.T.U.) 6.00
Incoby aullmrile representatives of this city t0 enter upon the BOILER-COMP(Over 100,0 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep Imnnless the City of MISC:- FER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way 'ecru, agm st said City in consequence.1 tile PERMIT ISSUANCE - 10.00
granting or ia MECH.CONT. - LIC.NO.. MECH.
D + TOTAL
S auo Conractor e TOTAL
OFFICE COPY "