C09689 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
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ADOR E55
if -7LLA( BUILDING - ELECTRICAL-PLUMBING-MECHANICAL `9,
OYDER'S 1 PLAN HECK VALIDATION
•} NAME - PTY. ELECTRIC PERMIT FEE
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NAMERncTORs \ OUTLETS-SWITCHES-RECEP 10.00/1.00 f/1'
LIC.ND. LIGHTING FIXTURES - 10.00/1.00
ANT ACTOR
ADDRESS (00"s-) -APPLIANCES-RESIDENTIAL 4.00
5 PRONE - 7 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN FEE P.c.NO.
OR
ENGINEE
IC.NO. SIGNS TRANS. 3.00
ADDRSRESENa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
AGOG ESS J/
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /
a u 1 hereby affirm Bmt 1 am licensed under provisions of Chapler 9 ISS ANCE DATE
N 1 (coProfessions Code,a my license is in full force,yld e e
mmencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH.
H N ' OL ❑
Z i w 6 License Class Lic.Number
I HI Date cpo_Cont rectory].'
P.
H -
It :e a a OWNER-BUILDER DECLARATION BUILDING PERMIT
R w v INFORMATION
wS > y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u a- . Law for the following reason.(See.7031.5.Businessmit Professions pERM1T ISSUANCE 10.00 ( (r�. VALUATION S/FT.
� - Code•.Any city or county which reyuiresa permit to construct,alter,
K2 ¢ Q improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.N0. EIEC. ,
oK relaires the applicant for such L
pP permit to'ilea signed statement that TOTAL�� PERM n w m m he is licensed pursuant to the provisions of the Contractor's License
HZ > Law(Chapter 9(conuneming with Section 7000)of Division 3 ofthe
- a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
r Oo the basis for the alleged exemption.Any violation of Section 703 LS STORIES- TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more tlwn five hundmd dollars($500).1.
❑ I,as owner of the property,or my employe..with wages as BACK FLOW PROTECT. DEVICE 4.00 - OCC,GROUP RES.UNITS
their sole compensation,will do tire u
e work,and the srae Ulre 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 improve,thereon,and who due,Sncll work FIXTURES-PER TRAP 5.00 _ SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improv.-
mentsare not intended cr offered lot
sole.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int E IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O 1,as owner of the Property, or exclusively'Contracting with ❑ ❑ , ❑ ❑
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
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-OV ER 5(EA.) 1.00
controcls.for such projects with a contracto(s)licensed pursuant to SEWER-SAN V-STORM EA.2001t/10.00
Bre Con Vector's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
resson -
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF:NSA'I ION DECLARATION WATER TREATING EQUIP. 5.00
( / I herebyaRtrm that I has,a certificate ofecasent to self-insure. ZONING ENG,SITE NO. '•
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). r
Policy No. Company
0 ❑ Certified copy is hereby furnished. �� FIRE SPRINK ENERGY T-24
z Z ❑.Cerhf1�L•�cp Iv with tl inspection division.
O AppliCanr�YYe�7, � MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
T CFRTIFICA'I'E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q UV FLOOD ZONE A.L.U.C.
LU > COMPFNSATION INSURANCE: PLG.CONTR. LIC.NO. PLG. T
d O (This section need not be completed if the permit is lot one TOTAL V E] NE) V E] N❑
::) Z hundred delta,,IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as In
O w become subject to lite Workers Compensation Laws of California. _//1�
y Dale applicant ALTER OR ADD TO MECH. 5.00 BUILDING FMiv'v/
}
to NOTICE 'f0 APPLICANT: If,altar making this Ccrtificme of Fi -
F Z emption,you should become subject to the Workers'Compersoliou APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lortbwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.N1) 4.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOSWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perlunnance of the work Ivor which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's e HEATINGUNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC �/
Lender's AddAddress
I certify that I have 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of This city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
(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
inay in anyw ay occme a• ' t olid City in conscyumme of the PERMIT ISSUANCE 10.00
g, rim of thrs Rnh. MECH.CONT. i LIC.NO. MECH.
� TOTAL TOTAL 3
ig azure of Applicant/Contractoractor Date �^
'J INSPECTOR COPY
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