09654 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
c APPLICATION & PERMIT
ADDRESS 09654
AODREss
C BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OVINEF�wNER'S PLAN CHECK VALIDATION
J
N
NAME QTY. ELECTRIC PERMIT FEE
P..N
cgMERAc*oRs OUTLETS-SWITCHES-RECEP 10.00/1.00
_ICxO, LIGHTING FIXTURES 10.00/1.00
ADDRESS DRAPPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
PHONE PANELS 10.00 - DATE OF APPLICATION
onCHITECT PANELS (OVER 200 AMP) 20.00 }• PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.
• c.NO. SIGNS TRANS. 3.00
ARCH,OR ADDRESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 J
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20.00 Gf
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< i w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m Q H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
s H z Professions Code,and my license is in lull force and effect ® ❑ ❑ u❑
i.o License Class Lic.Number
,A I- Al Datc Contractor -
`a x BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
¢
' o a U INFORMATION
tx3 LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
"
u O V Law for the following reason.(See.7031.5.Business and PrOfesvions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
Code:A ny city Or count y which real hi res a perm it to ConslmeI,al let, ELEC.CONTR. LIQ NO.
gyp'¢ a 2 improve,demolish,Or repair any structure,prior to its issuance,also ' ELEC.
D ¢ rMh11re5 the applicant for such permit t0 file a Signed Statement that TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe `'� �/
i a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE Y r 7
¢ gym the basis for the alleged cxmnplion.Any violation Of Scctiun 7031.5 STORIES TYPE CONSTR.
ILI
by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than live hundred dollars($500).7
❑ 1,as owner of the property,or my employees with wages as BACK-F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the IR.CtCrC 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 sell.builds or improves thereon,and who docs such work F IXTURES-PER TRAP 5.00 $Q FT.FLOOR AREA TOTAL ACREAGE
• ment,f'or lot ince his own employees,for sale,provided Ihat such im ilding
or loprre anent ien old or wthin plfyearl however,tile building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or)der wieme v is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.p INDUSTRIAL WASTE INTER. 30.00 RES IND 11 PB Omer
❑ d as owner of the property,he exclusively contracting with s
` licensed colons od to construct the project(See. does Business LAWN SPRINKLERS-1 INC 5 V.R. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds tr improvesenwil pl.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts Contractor's
L projects with a ronlruct"dsl licenwd pursuant to
the Contractor's Licensr Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reasuu
Owner �+^-�•.�-
Date d3 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COA '1i
NSA'I'[ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm 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 thereof(See 3800,Lab.C.).
Policy No. Company -
O ❑ Certified copy is hereby furnished. RE SPRINK ENERGY T-Z4
Z Z ❑ Certified copy is filed with the city inspection diviai"a
r0 Applicant MISC.- REFER TO ORD. YE] NE] Y [] NEJ
y CER'TIFICA7E Of:EXFMPTION FROM WORKERS' PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y[:] N YE) N�
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
lL I- mit is issued,1 shall not employ any person in any manner so as to
U U become subject to the Worker Compensation Laws of California'
a Date Applicant BUILDING Ov
} W NOTICE'1'0 APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forhwith 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
the performance of the work for which this peimit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lendeh Name
Lender's Address f HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Icertify that l have read this alsplication and stale that the above VENTILATION FAN (SINGLE) 4.00
• Information is correct.1 agree to comply with all city and county PLUMBING
ordinances and slate lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives for ins of this city t0 enter upon the 601 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspof this
city to
(WO 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 way accrue agams id City in contiequence of the PERMIT ISSUANCE 10.00
;ranting of MECH.CONT. LIC,NO. MECH.
.. .
c TOTAL TOTAL
Sig ore of pelican "mmetor Date
INSPECTOR COPY