09690 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
nBUILDINGrpV/=DDRESS APPLICATION & PERMIT
ewPM'Y�� P��K ,t1rs BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09690
OWNER'S PLAN CHECK VALIDATION
NAME /y�•// OTY. ELECTRIC PERMIT FEE
• Ciry VF Cvp9 'PHOE
CONTRACTOR'S
NAME F.rt4CC.rjwc OUTLETS-SWITCHES-RECEP 10.00/1.00
•$• C0/1SJ9V r"PAJLV*N � LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS .s J -A APPLIANCES-RESIDENTIAL 4.00
)
�trr ` % PHONE � zG PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE D.C.NO.
OR
ENGINEER
Llc.NO. SIGNS TRANS. 3.00 '
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRZIP EMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
,s< y (commencing with Section 7000)of Division 3 of the Business and BLDG. EL CT. PLG. MECH.
H w z Professions Code,and Iny license is in full force and effect. El El Elo 0 m W License Class Lic.Number
,A H Date Contractor
x BUI DING PERMIT
¢ aew u OWNER-BUILDER DECI,ARATION 1 ORMATION
w3 u y 1 hereby affum ilial I am exempt Gum the Contractor's License MISC.- REFER TO ORD u_ oe Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct.alter,
¢ ¢ p inlpwve,demolish,or repair nny struqurc,prior Io i15 issuance,olm ELEC.CONTR. LIC.NQ ELEC.
w_ K requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m o he is licensed pursuant to the provisions of the Contractor's License
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r m tire basis fotire m alleged exmnpliun.Any violation of Section]031.5 STORIES T CONSTR.
dam _ by any applicant tura permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
Heir sole compensation,will do the work,and the stmcture 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 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,provided that such improve-
ments are nol intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did n - . - . .
riot build or im- BUILDING USE
purposeRES IND 0 PB Other
prove 1,as owner
of theJ. INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ 1,as owner of the properly,am exchlsively contracting with
licensed contractors to comtruct the prOccb(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR P HCELNO.
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-OVER 5 (EA.) 1.00
contracts lorsuch projects with a contractuds)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ilse Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG.FILE NO.
WORKERS'COMP9NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby atfirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG:SITE NO.
copy themof(Scc.3800,Lab.C.).
'olic 'No. Company
O Certified 'Opy'is hereby'fumished. FIRESPRINK ENERGY T-24
Z Z Certifiedoy is fileclI h try inspection division.
O Applicant e '��� `„_' I'TIyINig,,,P REFER TO ORD. v ❑ N❑ Y ❑ N
c ❑
h �B:RTIPICATIi P IiXEMOPROM WORKERS* PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
OI > COMPENSATION INSURANCE PLG.CONTE. LIC.NO, PLG
CL . ❑ ❑o This section need not be completed if the permit is for on ❑ N Y e TOTAL v N E)
Z) Z hundred dollars IS 100)or less.)
•U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Q a Dnlc Applicant BUILDING
>_ to NOTICE '10 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
♦- ? 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
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE
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. 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
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree li comply with all construction,
county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby ention ed representatives for ins of this city to enter upon the BOILER-COMP lover 100,000.BTU)SEE FEE SCM.
shove-mentioned property for inspection purposes. MECHANICAL
(WO agree to save. indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way acme a 'inst said City in consequence of the PERMIT ISSUANCE 10.00
granting of this per ECH.CONT. LIC.NO. MECH.
��- �J TOTAL TOTAL /l
iRn ore u' pp kart/Contractor Date �V fee
INSPECTOR COPY