09631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BIDI LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0
ADDRESS
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
9631
OWNER'S [ PLAN CHECK VALIDATION
NAME //�� . OTY. ELECTRIC PERMIT FEE
L-d vrIDNE
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
N
LIGHTING FIXTURES 10.00/1.00
CONTRACTORSS APPLIANCES-RESIDENTIAL 4.00
q _ _ HONE y.Tf �•- p PANELS 16.00 DATE OF APPLICATION
ARGIITECT ,.
�7 G/9f�.. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
aR mer-w�. tia..-,•_.-+.:t• 8
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.06 PERMITVALUVUD
ZIP EMP.METER OR POLE INS. 20.00 !SEP O
ADDRESS MOTORS SEE FEE SCH. !" 19$g
ADDRESS 1JU
.ycA &-.;;,o- �j SERVICE CHANGE 20.00 {,�
° ¢ TEMP.POLE 30.00 ,Cloy �f Cupe�t�
r 0 0 LICENSED CON UECLAR A'f10N (Ip
a 0 u 1 hereby affirm that 1 am licensed under provisions of Chapter'.) ISSUANCE DATE
w zw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.
H D i I'rofessions Code,and my license is in full force and effect. ❑ El ❑
z 0 w - License Class(r'is_ A 9- Lie.Nwnhcr,t.j' �A L
o yH ° DA6-62a9_W-4 Contractor
BUILDING PERMIT
¢
Or 4 OWNER-BUILDER DECLARATION
a a° MISC.- REFER TO ORD ' INFORMATION
X 1 hereby affirm that I am exempt from the Contractor's License
S u VALUATION
H _ 0 Law for the following rea.oa(Scc.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 a
,AwCode:Any city or county which requires a permit to construct.alter, -
QQ4p improve,demolish,or repair any structure,prior to its issuanee,also ELEC.CONTE. - LIG NO. ELEC. _
° LL requires the applicant for such permit to file a signal statement that TOTAL IT TO
a w m w he is licensed pursuant to the provisions of the Contr.Ictor's License
HiQ
Law(Chapter 9(commencingwith Sect Io n 700Hol'Division Sol'the
f 4 ° Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE PE
¢ o the basis for the alleged exemption-Any violation of Section703L5 STORI 5 -TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN$ VENT-WATER (EA.) 5.00
of not more than five hundred doll...(5500).):
❑ 1,.s owner of tile property,or my employees with wages a. 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 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 Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
. himself re of rote his own cmred fors Provided thin such improves
mmnts are through
or offered ces,Provided
that r.suhe..IPro ng GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA.) 200
builder will have tile - . - . .
e burden of proving that he did not build or ini- BUILDING USE
prove for purpose of sada). INDUSTRIAL WASTE INTER. 30.00 R S MD CON PB Orme,
Cl I,as owner of the property,am exclusively contracting with _ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Pions Code:l'he 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 contractogs)licensed pursuant to SEW ER-SANITAR V-STORM EA.200tt/10.00
the Contractors License law\ TRACT NO. PARCEL NO.
Cl lam exempt under Sc,.-,11&P C.le,tris WATER HEATER W/VENTS 6.00
reason
Owner Date WATER SYSTEM5.00
I ACC.GATE ACC FILE N0.
WORK ER S'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have.certificate of comma to sal Gins.re, TONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(See.3800,-.ugab.C.)�- , 7/
Poll No.�fs hereby
ere ny
Certified copy isss file'f with tire
FIRE BPRINK ENERGY T¢4
Z Z Certified ropy is tiled with the city inspection division.
MISC.- REFER TO ORD.
Q Applicant V❑ IN V ❑ IN
w CE RTI 17 ICATB 01:EX ENI PT ION FBONI WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, y❑ NEI y ❑ N❑
CL Z( 'rhiS section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)(ir less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any niantter so as to
Uw hemme subject to the Workers'Compensation Laws of California. BUILDING
Q. Uate Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT': If,after nicking this Curtilicate of Ex-
2 eniption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tie Labor Code, you must forthwith comply with FEE
U such provisions or this permit shalt be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGLNCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 ,r i
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.) HEATING UNIT ITO 100,000 B.T.U.) 8:00 m
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Addre >-✓(,L_!''1' x/84-!'0 0 n ny_ ELECTRIC
Icertifythar'1B.14Atn?a pi.atioo and state that theabove VENTILATION FAN (SINGLE) 4.00P „moi
• 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 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence .(' tire .nn
gmntin of this Permit MECH.CONT. LIC.NO. MECH.
zn + TDT"` TOTAL
' Signature of Applicant Contractor Uhte s OG
INSPECTOR COPY
- I