9369 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTI FICATION PERMIT NUMBER
LICATION & PERMIT
BUILDING APP
ADDRESS
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 93600
OWNER'S PLAN CHECK VALIDATION
NAME - QTY. ELECTRIC PERMIT FEE
• Al ONE
AORs
OUTLETS-SWITCHNAMEES-RECEP 10.00/1.00
e ' uC.No LIGHTING FIXTURES 10.00/1.00
.o PPLIANCES-RESIDENTIAL 4.00
ADDRESS S nJ•rA
` „ Ory PANELS 10.00 DATE OF APPLICATION
l OR IECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER I
uc.NO. SIGNS TRANS. 3.00
EOR
arca SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00,�iiIPI
APPLICANTA
S MOTORS SEE FEE SCH. PAID
ADDRESS
SERVICE CHANGE 20.00
0 0 0 LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00 JUL K1985
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DAY '
ec (ronmncing with Section 7000)of Division 3 of the Business and
ti Q H mBLDG. LE PLG. MECH.
r y z Professions Codc, t my license is in full tixce unit effect.
r, o u, License Closs_�.efCL Liu Nunr[71��
.he . �. 'U (n
9 Z Dal, Contractor
a Y a J
BUILDING PERMIT
¢ ¢ w ¢ OWNFR-BUILDER DECLARA'T'ION
o N INFORMATION
wg I.hereby affirm that I and cxenlPt from the Contractor's License MISC.- REFER TO ORD
LL o as as Law for the following reason.(Sec.7031.5,Business and Professions pERM1T ISSUANCE 10.00 i- VALUATION $/FT.
� - 0 Code:Any city or county which requires a permit to construct,alter,
or a improve,demolish,or repair any structure,prior to its issuance,alsoELEC.CONTR. LIC.NO.
n ELEC.
¢ LL requires the applicant for such permit to file a signed statement that TOTAL
wso
m he is licensed pursuant In tiro provisions of the Contractors License PERMIT TO
Fz > Law(Chapter 9(rommcncing with Seaham 7000)of Division 3 oftlre
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
s i o
by basis for the alleged exemption.Any applicant
of SecOom en LS STORIES TYPE CONSTR.
ate _ .fuel applicant lora permit theapplicam toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
.fuel more than five hundred dollars($500).):
❑ 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 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
ments are not intended oroffered for sale.If,however•the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . -
the owner- GAS EASYSTEM OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
purpose RES IND CON PB Other
pro forsownerofsaie1. INDUSTRIAL WASTE INTER. 30.00 0 ❑ ❑ ❑ ❑
❑ I,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
to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts far such projects with n contractor(s)licensed pursuant to
He Contractor,License Ltw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 heroby UILnn that I have a csUiticat,of consent to sell-lao,o, ZONING ENG.SITE N0.
or a certificate of Workers Compenwtion Insurance,or a certified
copy thereat(Sec.3800,Lob.C.).
Policy No. Comp:my
(] ❑ Certified copy is hereby 1 fished' FIRE SPRINK ENERGY T 24
Z 2 A,Certified _oCantlL p is wi the city insp• i n Division.
Q IlMISC.- V REFER TO ORD. ❑ N V ❑ No
CC rn cERTI71 r TE 01'1iXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLO.CONTR. LIC.N0, PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y E] NE] Y C] NEI
Imndred dollars(S 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 U mit is issued,T shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
LU Date Applicant BUILDING
Is.>_ y' NOTICE TO APPLICANT: IL after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
H ? t Lemption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labpr Code, YOU most forthwith comply with FEE
U such provisions or this permit shall be dean ed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.EM.) 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 permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's No.Addy H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC ^ �
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is mrreet. I agree Io comply with all city and county BOILER-COMP(3 H.P,of 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws reluting to building construction. and
hereby authorize representatives of this city Ip enter upon the BOILER-COMP (Over 100,000 BTUI BEE 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 cue I, against Sui, City i co risequence of the !
granting of this per l (/ MECH.CONT. LIG.NO. MECH.
TOTAL TOTAL 1�
Date .�
INSPECTOR COPY
u