09679 I f
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
aD ILDING APPLICATION & PERMIT 09679
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ADDRESS I 1,1 C t,
t . 9e-? dA/ a/t BUILDING- ELECTRICAL-PLUMBING-MECHANICAL i096 9
OWNER'S U V C'7 V - - - PLAN CHECK VALIDATION
. NAVE m r '127 QTY. ELECTRIC PERMIT FEE
PHONE
CNT
croEs
HUME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
C,ONTRACTOR's APPLIANCES
4.00
ADDR SSS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE v,C.N0
OR .
r
O
ENGINEER
UC.No. SIGNS TRANS. 3.00
AARC
DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00 �J
APPLICANTS
ADDRESS A MOTORS SEE FEE SCH. K -f,V.-d..r•�
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 ��/f
¢ u u I hardly affirm that I an, licensed under,provisions of Chapter 9 ISSUANCE DATE
so c m (commencing with Scc(ion 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H o z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o w - License Class Lie.Numher
oz - . Date COmructor
`a a, BUILDING PERMIT,
¢ ¢ a OWNER-BUILDER DECLARATION o a O MISC.- REFER TO ORD INFORMATION
w 3 n I hereby afrirm that I am exempt from the Contractor's license VALUATION
FLLO4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 1I '1
Code:Any city or county which requiresa permit toeonstruct,alter, �L
¢ ea Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. + Y
-O a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License -
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe - /�O ^
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 11
¢ o the basis for file alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
aim by any applicant lora permit subjects the applicant His civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five(hundred dollms(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCG GROUP RES.UNITS
inmhded or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does Suebi work FIXTURES-PER TRAP ' 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
hi nlself re through his own employees, k.If,however,that-such improve-
nseu6mrlot throulendedorofrnployed rsule.ILed that such
building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
or improvement .s sold within one year(It completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that Ile did not build or im- BUILDING USE
prove l'or purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Omar
❑ 1,us owner of the properly,ant exclusively contracting with ❑ ❑ ❑ ❑
licensed cuntruclors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 F ASSESSORS PARCEL NO.
and Professions Code! ['lie Contmetor's License Law dues not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlracmKs)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ loco oxempt colder 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 _
I hereby affirm that I have a certificate of-consent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sce.3800,Lab.C.).
Policy No. Company
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z z ❑ Certified copy is riled with the city inspection division.
0 Applicant MISC.- REFER TO ORD. Y ❑ N❑ v ❑ NE]
y CHRTII'ICA'ri:OP EXEMPTION('ROM WORKERSPERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
L COhIPENSATION INSURANCE PLG.CONTE. LIC.NO. .PLG. v❑ N❑ v❑ N❑
Q Z fl'his Section need not he completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U 0 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 enmloy any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE '10 APPLICANT: IL after nmking this Certificate of Ex-
F z mnption,you Should beconm subject In the Workers Compensation APPLIANCE 5.00 PLAN CHECK / -(
provisions of tire labor Code, you must forthwith comply with FEE lP
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'fRUCI']ON LEaNDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMICFEE
I hereby atfinn that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
3097 re �CivrC.)" cd of the work for which this permit is issued(Sec. HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING 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 ncorrect. ( agree to comply with all city and county BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
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 harmlessthe City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX 14
may in any-way accrue against said City in consequence of the
✓•
granting ol ',parmit. MECH.CONT. LIQ NO. MECH. ;:X--
1/ TOTAL TOTAL
(gnat Im el Applicant/Co r ate
INSPECTOR COPY