09901 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 1
BU I LDING PROJECT )DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
755 1
7 AD � 1 � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 09901
- OwNER'S d1 PLAN CHECK VALIDATION
1 NAME QTY. ELECTRIC PERMIT FEE
hAr PHONE
1 $ 946-3008
CONTRAC R'B
NAME �L�H47� �C/Zd,GCJ OUTLETS-SWITCHES-RECEP 10.0011.00
f. 1'4 , s Q.} LIC.NO. yy (, LIGHTING FIXTURES 10.00/1.00
.ONTRACTORs PPLIANCES-RESIDENTIAL 4.00
AiA�D/ORE55( ✓1 ((L�
. ss_ ")..1Q -1( teee PHONE '_ 9_11h1 PANELS 10.00 DATE OF APPLICATION
ARCHITECT S � /lS ' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
On l
ENGINEER
uc.No. SIGNS TRANS. - •- 3.00
ARCH ass ENc' SPECIAL CIRCUIT t,•� 6.Dg PERMIT VALIDATION
ZIF TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 / ( (
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
ao U I hereby affirm that I am licensed under provisions of Chapter') ISSUANCE GATE
H ¢ w (conunencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w z Professions Code,and license is in full force aqqd fecy�i � 5
z o m -� 1Jcense Class Li, Number `7 El 11 ®�
)
9 z tQ DaleJ 21 1 Contractor 1- „ 1 s s'
BUILDING PERMIT
¢ ¢ w ¢ OWNER�BUILDER DECLARATION INFORMATION
F DAD MISC.- REFER TO ORD
wg: , N 1 hereby affirm that I am excmpl from the Contractor's License VALUAT151 S/FT.
FUD¢ Lawfor the followingrcawn,(Sec.7031.5.Business and professions
PERMIT ISSUANCE 10.00
Code'.Any city oreuunty which requires a permit to eonstr¢L alter,
of tt¢improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
as DLL requires the applicant for such permit to file a signed stulmricat that TOTAL PERMIT TO
' w m he is licensed pursuant to the provisions of lire Contractor's License
FZi Law(Chapter 9(co an me tic ing wit It Sect ion 7000)o f Div ision 3 of I he
- ¢ Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
¢ r O lire basis for the alleged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; ° by any applicant fora permit subjects the applicant toa civil penally
ofuot mora than five hundred dollars($500).): ALTER-DRAIN -WATER (EA.) 5.00
❑ 1,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,wrd lire structure 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 docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOORAREA TDTALACREAGE
himself re through his own emred fors, le.I f,ho that such improve- _
mems are not through
or offered for sulrovided that s,tbebuihlle- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving ilial he did not build er inr . RES IND COM PB Omar
prove for or caner of the.l. INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑ '
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply 1
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts torsuch projects with a contmetorls)licensed pursuant to SEWER-SAN EA.200k/10.00
line Contractors License Law. TRACT NO, PARCELNO.
O Iain exempt under Sec.-,BAP.C,for this WATER HEATER W/VENT 6.00
reasnn
Owner Dale WATER SYSTEM / 5.00 ACC.DATE ACC FILE NO,
WORK ERS'COMPENSATION DECLARA NON WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self:insure. J ZONING
x or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,1ab.CJry 7
Policy No. Company`/'-° h 1n•C �J /
O ❑ Certified copy ishmebyfurmshed. 1 FIRE SPRINK ENERGY T 24
z•a� ❑ Certify'ed o y filed with the city inspection division.
O� Applicant^' t ( /r.aa 5..,✓.n MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ w ,F j'%-/- ;raPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CERTIFICA Ii U11_ EMP ION I'I�rM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
a Z( This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars IS 100)or Tess.)
U O 1 certify that in the performance of the work for which this per- OT)' MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner eo as 10 T
U become subject 1.the Workers'CompensatmH Lawsof Calif oro ia. BUILDING
a Datc Applicant ALTER AOR ADD TO MECH. 5.00
} m NOTICE '1 O APPLICANT: If,after making this Certificate of Ex-
F ? 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 - SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of lire work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 tN
Lender's Name
Lenders Addre HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that 1 have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00 -
information is correct, I agree to comply with all city and county PLUMBING '
onlinanees and state laws relating to building construction, and B01LER-COMPI3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 001 LER-COMP I Over 100,000BTU)SEE FEESCH. MECHANICAL!' GU
above-mentioned property for inspection pugloses.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 t/L CONST.TAX
may in any way accrue against said City in conseq ounce of the
g�ramljingoflhis pe... MECH.CONT. LIC.NO, MECH.
//G//// ✓ -_�. /O/�G/ TOTAL/9 ` TOTAL
Siggnnature of Applicant//Contra or Diijit
INSPECTOR COPY
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