8779 1 ti 11APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMITS
'AODR _ 8779
• Es
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
h OWNER'$ N. PLAN CHECK VALIDATION
NAME ELECTRIC PERMIT FEE
vdl norvE
NAMERn T OUTLETS-SWITCHES-RECEP 10.00/1.00
L�1IGHTING FIXTURES 10.00/1.00
rory crony. PPLIANCES-RESIDENTIAL 4.00
AooFEss
•E PANELS 10.00 DATE OF APPLICATION
onnLNI c PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCHEss ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS
SERVICE CHANGE 20.00
M 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
h G U t~i ' I hereby affirm that 1 am licensed under previsions of Chapter 9 ISSUANCE DATE
w¢ w (communcing with Section 7000)of Divifiioa 3 of the Business and BLDG. ELECT. PLG. MECH.
D z Professions Code.:uul my license is in full forcWill!. ❑ ❑ ❑
oO y W' License Class Lic.Number13 v
2 m r_ J Dale '��J Contrator
m 1 BUILDING PERMIT
5 o i O li UILDHR DIiC1.ARA"I'10N INFORMATION
�w LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u_0 4 Law for the following reason.(Sec.7031.5,Benno,s dad Professions PERMIT ISSUANCE 10.00 VAtAATION 5/FT.
Code:Any city or county which requires a permit to const ruc(,alter,
e cr ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.NO. ELEC.
La u0
, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w he is licensed pursuant to the provisions of the Contractor's License
FiQ
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
Business and Professions Code)or than he is exempt ()4� �
therefrom and GTY. PLUMBING PERMIT FEE /
¢ f0 the basis for lire alleged exemption.Any violation of Selim,7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA.) 5.00
•a of not more than live hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wake,as BACK FLOW PROTECT. DEVICE 4.00
(their sole compicimad ion,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 huilds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.FT FLOOR AREA TOTAL ACREAGE
e himself or through his own employees,provided that such inhpow'-
meets ure not intended or offered for sale.IC 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 (EA.) 200
builder will have the burden of proving that Ie did not build or int . - . .
. BUILDING USE
prove to,purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer,
17 I,as owner of lire property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
�„••l licensed'contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:Tire 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 for such projects with a contractons)licensed pursuant to
the Contractor's License Law. a SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See ,B.&P.C.for thisWATER HEATER W/VENT 6.00
om on
Owncr Dam WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
W'ORKERS'COMPENSA"PION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
ora certificate of Workers'Compen lion Insurunpe,or a certified
I' C• CC�}py�W,(IJ��dn ll, I'/I1/'►„_ vis 11Y-.
copyt is S 4wr11 In d. FIRE SPgINK ENERGY T24
Z Z ❑ Certifi capY is fled wit t e cit inspection v'i t
F O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
W CERT FI:ATL!It11:x1: PTION PROD WORKIiRS' PERMIT ISSUANCE 10.00 L000 ZONE A.L.U.C.
W CONPHNSA'ITON INSURANCEPLG.CONTR. LIC.NO. PLO. V N❑ v ❑ NE]
0 (This seat need not be completed if the permit is for one IT
OTAL
hundred dollars IS 100)or less.)
U'O I certify that in the perfornhance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U beco ne subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT': IL after nuking this Certificate of L:x-
FZ enghtion,you should.beconia subject to the WorkersCompensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, YOU must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.NL) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 100ODC.F.M.) 6.00 SEISMIC FEE
I hereby affirlm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of She work for which this permit is issued(See. 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 y e to comply with all city and countPLUMBING
ordinances and orate laws refining n building construction, am]my BOILER-00MP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any 'ay accrue against said 9ty in consequence of the PERMIT ISSUANCE 10.00
ting Of lhl ermiLECH.CONT. LIC,NO. MECH,
TOTAL TOTAL
SO4aturtirlAVr;liBunuticsraitirtictesr at
INSPECTOR COPY
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