09745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
xBUILDING APPLICATION & PERMIT 0745
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
7*194 40e,& A,«e
OWNER'S - PLAN CHECK VALIDATION
NAME ZSJ=dt9J8 OTY. ELECTRIC PERMIT - FEE
^ PH-NEa6z_,o R70
NOMERAcroRs UTLETS-SWITCHES-RECEP 10,00/1.00
Lie NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES
PHONE
4.00
AOOR E55
PHONE PANELS 10,00 DATE OF APPLICATION
ocNr
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK PEE P.c.No.
on
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH ORENG, SPECIAL CIRCUIT S.DO PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTODRESSMOTORS SEE FEE SCH. /f -
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(conuncncing with Section 7000)of Division 3 of the Business and
G G u BLDG. ELECT. 1. PLG. MECH.
r m i License
ase Cla Coda,and Iny license is in full lilrcc and effect.
2 o w - License ClassLic.Number
9 - Date Contractor
a m BUILDING PERMIT
¢ ¢o n OWNER-BUILDER DECLARATION INFORMATION
Z
;u m I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO�ORD
u04 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION
Code:Any city or county which requiresa permitloconstramLalleq
rta Q a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
w- O LL o, ,d..'s the applicant for such permit Io file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
HZT Law(Chapter 9(eonlcoercing with Section 7000)of Division 3o fthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
i o
¢ F $ the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
a i by any applicant for a permit subjects the uppli"mt to a civil penalty ALTER-DRAIN VENT-WATER (EA.) 5.00
of not more thwl five lumdred dollars($5001.)'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and lire structure is not OCC.GROUP RES.UNITS
intended or offered for sale (S6c. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'Ilse Conlractor s License Law docs not apply to ml owner of
property who builds Or improacs thercon,and who does such work FIXTURES-PER TRAP 5.00 BQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improvo- .
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 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 int - . IEA.
1I BUILDING USE
Prove for purpose of ad,f INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the Project(Sec, 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner __ Y. T Date 9 A WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate ofconsent to self-insure ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thcrect(Scc.3800,Lab.C.). -
Policy No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY 44
Z Z O Cerlilied copy is filed with tie city nt,c:two division.
O Applicant iMISC.- REFER TO ORD. Y ❑ N❑ Y ❑ IN
LO CERTIFICATE OP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMI'IiNSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (this section need not be completed if the permit is for one TOTAL Y E] N❑ Y[3N❑
hundred dollars(S 100)or less.)
0 O 1 certify that In the performance of the work for which this per. TV. MECHANICAL PERMIT FEE FEE SUMMARY
LU 1- mit is issued, I shall not employ any person in any planner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
>_ to NOTICE TO APPLICANT' If,after making this Certificate of[,a ALTER OR ADD TO MECH. 5.00
F ? emption,you should become subject to the workeo'Compensation APPLIANCE 5.00 PLAN CHECK
L.7 prvisions
siovisof the this
Code, you most forthwith comply with FEE
p permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction tending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work lot which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name 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 Rte above VENTILATION FAN (SINGLE) 4.00
information is cmrrecl. I agree to comply with it 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 ur
pposes. L�
(We) agree to save, indemnify and keep harmless the City d MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00Q� --
granting of this permit.\\\ MECH.CONT. LIC.NO. MECH.X/ _ TOTAL I f I/V
SlTOTAL
µn�ure olFAppl¢u�Conlradnr IJale
INSPECTOR COPY
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