09690APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09690
nBUILDINGrpV/=DDRESS
ew Pjw)C �,9,Iz;;r Tt*Ald
OWNER'S
NAME /y�•//'I
Ciry VF Cvp9'PHOE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S'
NAME F.rt4CC.rjwc
•$•CPAJ7 f�UPrJ PAJLFN
OUTLETS -SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S-AAPPLIANCES-RESIDENTIAL
ADDRESS .� J
4.00
�/.`'(j C % PHONE 72
`
DATE OF APPLICATION
PANELS 10.00
OR
ENGINEER
LIC, NO.
PANELS(OVER 200 AMP) 20.00
PANELS
PLAN CHECK FEE D.C. NO.
'
SIGNS TRANS. 3.00
ARCH. ss ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
APPLICANT
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license ism full force and cflect.
License Class Lic. Number
ISSUANCE DATE
BLDG. EW. PLG. MECH.
El ❑
Date Contractor
BUI DING PERMIT
I ORMATION
OWNER -BUILDER DECLARATION
I hereby collo that I am exempt from the Contractor's License
CodeLaw forthecity countng alon.(he.7031.5, uilesa perminessand Professions
Code: Any city or county which requirese permit to Construct. alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
ELEC. CONTE. u0. NQ ELEC.
TOTAL
improve, demolish, or repairany p rmit toff prior to is issuance, also
for such permit ns file a signed statement that
ren vires the dp pursuant
he is licensed pursuant Io provisions of the Contractor's License
PERMIT TO
(Chapter 9 (commencing with Section
ing of Division 3 0l the
Busi
Business and Professions Code) or that he is exempt therefrom and
is exempt
DTV. PLUMBING PERMIT FEE
aba,por int or ad exem shun. Any vapplica of Sccl ion malty
by any
by any applicant fire permit subjects $500),licanl tYa civil penalty
of not more than five hundred dollars (5500).):
STORIES
T CONSTR.
ALTER -DRAIN VENT -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
.
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's license Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
ments are nol intended or offered for sale. If, however, the building
so. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did n
riot build or im-
- . -..
GAS EASYSTEM OVER 4 IEA) 200
BUILDING USE
purposeREB
of theJ.
prove 1, as owner
❑ 1, as owner of the property, am exclusively contracting with
IND 0 PB Other
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the prmect(Ses. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASBEBBOR PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
theCo tstitoWs LicenecLts withumntranol(sl licensed puauum to
the Con(racloi v License Law.
❑ I am exempt under Sec.-, BAP.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL N0.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACG. FILE NO.
WORKBRS'COMPtiNSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure.
ZONING
ENG: SITE NO.
or a certificate of Workers' Compensation Insurance, or a certified
copy themof(Scc. 3800, LIDC.).
Colic INo. Company
.
Certified copy' is hereby' famished.
certified oy is filedrsLLh yb ty inspection division.
Applicant a _� -
FIRE BPRINK
v ❑ N ❑
ENERGY T-24
Y ❑ N❑
MISC. - REFER TO ORD.
I'TIig,,,P
��`„
�B:RTIPICATIi P IiXEMON PROM WORKERS*
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
y❑ N❑
V❑ IN E]
PLG. CONTE. LIC. NO.
PLG.
TOTAL
hundred dollars IS I 00),)L less.)
1 certify that in the performance of the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation Laws of California.
ALTER OR ADD TO MECH. 5.00
Dale Aliplicant
BUILDING
NO'T'ICE '1'0 APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
FEE
'
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10)000 C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that 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.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state that the above
information is correct, I agree bI comply with all city and county
ordinances and stale laws relating to building construction, and
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00
hereby amborue representatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
BOILER -COMP lover 100000.BTU) BEE FEE SCM.
.
MECHANICAL
(We) agree to save. indenmify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments. costs and expenses which
may in any way acme a'inst said City in consequence of the
PEflM1T ISSUANCE 10.00
CONST. TAX
granting of this per
ECH. CONT. LIC. NO.
MECH.
n
- ae' - �J
TOTAL
TOTAL
/l
iRnore u' pp icant/Contractor Date
INSPECTOR COPY