09898 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
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BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09898 98
OWNER'S PLAN CHECK VALIDATION
NAM / ' (IQTY. ELECTRIC PERMIT FEE
CONT ACTORS f.
y rvAm 7 OUTLETS-SWITCHES-RECEP 10.00/1.00
1. 1 LIC.NO. /2 2360L LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
�! yq'Q Ik IPHONE C1710111 PANELS 10,00 DATE OF APPLICATION
/
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ARCO OR ENG. SPECIAL CIRCUIT S.QO PERMIT VALIDATION
ADDRESSZIP EMP.METER OR POLE INS. 20.00 PAID
ADDRESS AMOTORS SEE FEE SCH.
DRESS E55
SERVICE CHANGE 20.00 OCT
o w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,•4 U C
¢ u v I hereby affirm that 1 am licensed under provisions of Chapter 9 iller, ASSIJE�ISNOEE
I
a a (commencing with Section 7000)of Division 3 of the Business and BE ME H
O 0 V,i License cls Code,and m�ice.Li
.in full for a¢d.effc
0 O m License Class L Lie Number ❑ 11 ❑
r w Dare Contractor ( Lrm-�fiw//
a•x s BUILDING PERMIT /
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o a u INFORMATION
X 3 LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Imo ¢ Law for the following reason. 7031,5.Busmasand Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
� - 0 Code:Any city orcounly which requires a permit to construct,alter,
¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
iL O LL requires the applicant our such permit to file a signed statement that TOTAL
P R ITT
d w m he is(Chapter
pursuant m the provisions of the COntmctor License
in Law(Chapter9(commencingwith Section 7000)ofUlvision3of0e .
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
o thehaeis fur the alleged exemption.Any violation of Sectiun7031.5 STORIES �TVPE CONSTR.
s- by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -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 structure is not
intended or offered for sale (Sec. 7044, Business and 1'rofessioos DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors 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.PT.FLOOR AREA TOTALACREAGE
-� himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement 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 am. BUILDING USE
prove for purpose ofselc.)' INDUSTRIAL WASTE INTER. 30.00 RE5 IND PB Omer
Q I,as owner of the property,am exclusively contracting with 1:1C 1:1 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR pARCELNO.
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 IEA.) 1.00
contracts for such projects with a contractorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ore Contractor's License Law. TRACT NO. PARCEL NO.
❑ I um exempt tinder Sec.-,IL&P.C.for this WATER HEATER W/VENT 6.00
naso.
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKP-RS'COMPE NSATION DECLARA'T'ION WATER TREATING EQUIP. 5.00
1 hereby ullirin (but I have a certificate of consenl to self-insure, ZONING ENG.SITE NO.
or a certificate Ot Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lah.CJ.
folicNo Contrary IF 14/_rG InD
O ertified Copy'is hereby lumished. FIRE SPRINK ENERGY T-24
z Z ❑ orheJ a fled withlhuits 'nsrcction division.
O APplim tom•- ---�¢--� MISC.- REFER TO ORD. y No , y ❑ NE]
~ y
LU - .GR'I'T PICGPE EXENPTIFROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UL.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y N� V IN
Z (Phis section need not be completed if the permit is for one TOTAL
hundred dollars(51001 or less,)
L) 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
O 0 become subject tD the Workers'Compensation Laws of California.
d Date Applicant S ALTER OR ADD TO MECH. 5.00 BUILDING
} UB NO'I ICE '10 APPLICAN'1: If,after making this Certificate Of Ex-
H Z mnption,you should hecome subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DC.F.W 4.00
CONS'I'RUC'I']ON LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby Whitt the there is a construction lending agency I'.. EXHAUST HOOD (WITH DUCT) 5.00
the perlivmmnce 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
Lenders A Addrress ELECTRIC
I certify first I huvu read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building Construction, and Iii BOILER-COMP(3 H.P.or 100,000 B,T.U.) 6.00
herchy autlorixe representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
/ abovesnemtioned 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gramiogofthis permit, _ MECH.CONT. LIG NO. MECH.
//I-//4->' TOTALVl TOTAL
Signature of Applicant/Contractor Date X70-/
INSPECTOR COPY