09749 n
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_ BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
'WILDINas
G APPLICATION & PERMIT ADDREoy� Eos+ fit
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 09749
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• PMON s
NAMERAcroR's UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDR ESE
PHONE PANELS 10.00 DATE OF APPLICATION
OHCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FrEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 /
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a t I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
in z "' (commencing with Section 7000)of Division 3 of Ore Business and
a n BLDG. ELECT. PLG. MECH.
H H i Professions Code,and my license is in(all force and effect ❑ -1 ❑
oi m o License Class Lia Number
m H w Dale 'Contractor
a M f J BUILDING PERMIT
¢ o Ic D OWNER-BUILDER DECLARATION INFORMATION
X I hereby affirm that I am exempt from the Commctor's License MISC.- REFER TO ORD
3 a-ri. VALUATION $/FT.
F LL 0 a Law for the Ibllowing R.S.R.(Sec.7031.5,Business:uul l'rol'cssions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to constmet,.flet, _
K ¢ improve,dentulist,,or repair any Structure, luor to its 1,suanec,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such per it to file a signed sWtmnenl thin TOTAL PERMITTO
K
m w he is licensed pursuant to the provisions ol'the Contractor's License
HZQ
Law(Chapler9(commencingwith Section 7000)of DivisioR3 oflhe
E 4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H p the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
aim by any applicant lot a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more Than five hundred dollars(S500).):
❑ 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 Otr
re work,and tlm Sucture 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 TOTALACREAGE
himself or through his own employees,provided that such in'
prove-
mentsarc not intended oroffered for SaleIf,however,the building GAS-EA.SYSTEM-I 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
budder will have the burden of proving that he did not tire
or im-
Prose t'orpurpose ofsalu.). INDUSTRIAL WASTE INTER. 30.00 RES IND _ CON PB Omer
I� 1,as owner of the property,am exclusively contracting with - El ❑ ❑ ❑
tic n_sed 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 docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
conlruns for such projects with a contractor(s)licensed Pursuant to
the Co
License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ Inco exempt under See ,B.&P.C.ter this WATER HEATER W/VENT 6.00
rcoson
Owner s -/lig-�./' Date WATER SYSTEM 5:00 ACC.DATE Ace.FILE No.
WORK ERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 5.00 ,
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab C.).
Policy No. Company
0 ❑ CeHilied copy is hereby furnished. FIRESPRINK ENERGY T 24
Z Z ❑ CeniOed.copy is filed with the city inspection division.
p Applicant MISC.- REFER TO ORD. Y❑ NO , Y ClN❑
~ va PERMIT ISSUANCE 10.00
LU - C 1 R'I'I FICCOf iOP EXE;h1 N INS FROM WORKIiR$' FLOOD ZONE A.L.U.C.
W > COM17 F'IiNSAT10N INSURANCE PLG.CONTR. LIQ NO. PLG.
CI (This seetiou need not be completed if the pe nn it is for one TOTAL Y❑ N❑ Y [:] N❑
hmtdred dollars(_$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 mil is issued,I shall out employ any person'm any..norm..so as to
U become subject to the Workers'Compensation Laws of California.
a Date Applicant BUILDING
} N NOI ICIi TO APPLICANT: If,after making this cert it icale of is. ALTER OR ADD TO MECH. 5.00
r z emotion,you should nucome subject to the Workers'Colnpensmion APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT 100,000 B.T.U.)9.50
Lenders AddD,Names ELECTRIC
I certify that I have read this application and slate Otat the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building on 'I('
and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
ubovo-mentioned property for inspection purpo BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL /SwV
a"
(We) agree to save, indemnify and keep harmless the City o1' MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expclrses which PERMIT ISSUANCE 10.00 U CONST.TAX
may in anyway ucc ago' 't said City in conscquenu of the
grants fitErin ECH.CONT. LIC.NO. MECH.
"�`" TOTAL / TOTAL
mat ApP n calor Date ete
INSPECTOR COPY
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