09563 (2) APPLICANT TO, FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY K� J�
BU I LDINGPROJECT I IDENTIFICATION " PERMIT NUMBER .
BDIL.ING APPLICATION & PERMIT 09563
AUILOIN
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
• ME - ^ _� OTY. ELECTRIC PERMIT FEE!
Prs.NE
CONTRACTORS
NAE /\aUTLETS-SWITCHES-RECEP 10.00/1.00
llf4�0 {'� Llc.rv.. LIGHTING FIXTURES 10.00/1.00
ADNTRADREcrOR'ss ESS vA,Lt Ct lk-t(P PPLIANCES-RESIDENTIAL 4.00
CO
I SS
C G PHONE 35,'0S1(P PANELS 10.00 DATE OF APPLICATION
ARCHITECT _ PANELS (OVER 200 AMP) 20.00
ENGINEER FEE P,C.N0.
OR
ENGINEER LIC.No, • SIGNS TRANS. 3.00 s
aooeEss ENG' SPECIAL CIRCUIT 5.00 PERMI N
ZIP ITEMP.METER OR POLE INS. 20.00
NOV
ESS N
- MOTORS SEE FEE SCH. 'Y 71985
ADDROOR E55 -
SERVICE CHANGE 20,00 p�I/
O o o, LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00 yl'+ �f.CU �(lo
a v1 hereby affirm that 1 am licensed Under provisions of Chapter') ISSUANCE GATE
z w (connmemm�g wiSection 700 )of 3 othe Business and
ri, a th 0f Df
BLDG. ,ELECT. PLG.
H m z Professions C ny license is in full
License Class Lie.NumbA Tf�/'� J dL�sCLC•� I ElElElo i w o s
H m H wi Dale I-�_ Cuntmctor_A1-L_�
a m s V T
is a OWNER-BUILDER DECLARAATIONION BUILDING PERMIT
z o a u - INFORMATION
K
; LL h I hereby allium that 1 am exempt from the Contractors License MISC.- .• REFER TO ORD
Hao J Law for the following reason. 7031.5,Businessand Finemans PERMIT ISSUANCE 10.00 VALUATION g/FT.
Code:Any city-or county which requires a permit IT construct,alter, -
Qto Q 0 Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. • ELEC.
O o requires the applicant for such permit to File a signed statement that -- ,TOTAL - PERMITTO
AT
he Is.licenseJ pursuant to the provisions of theContractor's License -
Hz s- Law(Chapter 9(commencingwith Section 7000)of DivSmr3 ofthe --
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
f i o
¢ I- $ the basis for the alleged exemption.Any violation of Section 7031.$ -1 '� STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant to a civil Penalty ALT ~-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500).): -
❑ I,as 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 st ruclure is not
intended or offered for sale (Seo. 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,provider)the)such improve-
ments are not intended or offered for sale.If,however,the building - GAS'-EA.SYSTEM-1'INC.4OUTLETS 6,00 '
or improvement is sold within one year of completion, the owner. GAS EASYSTEM OVER 4(EA ) 2.00
builder will have the burden of proving that h - . - .
e did not build or im- BUILDING USE
prove for purpose of sale.). .. INDUSTRIAL WASTE INTER. 30,00 IND CON PB Orher�
❑ 1,as owner of the property,am exclusively contracting with y'•[iQ ��.
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 .. gSSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply '
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
emvmets for such projects with it contractor(s)licensed pursuant to SEW ER-SANITAR V-STORM EA.200k/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑- lam exempt under Sec. '',B.&P.C.for d]lis WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby Sau�ffirm that I have a certificate of consent to self-insure, I -ZONING.R ENG.SITE N0.
or a c T. O f-W rk CgmncnwI ion 1 sumac ur.a ce ficd
co PYM(�rf6'JFY .j,Q Y.LyJ(,� (
Pnliey3dv ' -`T�n a y_4 4LLV,e
O O Certified copy ishcony furakta, FIRE SPRINK ENERGYTZ4
'Z Z ❑ Certified coy is Filed with the cit inspection division.
O Applicant -f - -^ - - - -z ma1---' Misc.- - REFER TO ORD. .v N❑ v N�
~ rn �iT< PERMIT ISSUANCE 10.00
CERTI PICCO i ENSAI EXEMPTION N KIiRS' FLOOD ZONE A.L.U.C. ,
W � COA1Pf:NSATION INSURANCE PLG.CONTE. LIC.N0. PLG.
0. Z
This section need not be completed if lite pe nn it is for one TOTAL Y N� V E] No
hundred dmI.,s(S100)Or less) -
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
Ow become subject to lite Workers'Compensation Laws of California.
n Date Applicant - BUILDING'
} m NOTICE TO APPLICANT: If,after making this Certificate of fix. ALTER OR ADD TO MECH. 5.00
(_ Z emplion,you should become subject to line Workers:Compensat inn APPLIANCE' 5.00 PLAN CHECK'
provisions of tate Labor Code, You must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for. EXHAUST HOOD (WITH DUCT) 5.00
lite performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 6V -
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address - - ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. France to comply with all City and county PLUMBING•
,ordinances and state laws relating to building construction,'and] BOILER-COME(3 H.P.or 100,000B,T.U.) 6.00
hereby,aulhoriLe representatives of this city m enter upon the BOILER-COMP(OW,,100,000 BTU)SEE FEE SCH. MECHANICAL
\ / above-mentioned property!.,inspection purposes. -
r •�/ (We)'agree to save, indennnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 0.00 U CONST.TAX
may ' an way ru
acce against said City in consequence of the
.. gra ti [ i Pennif�l N0 T }
TOTAL
Sign urea Applicant/Cont 'clor Date
OFFICE COPY