9305 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS 7 If , APPLICATION & PERMIT. ���
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ' PLAN CHECK VALIDATION
NAME s QTY. ELECTRIC PERMIT FEE
oNE
CA A Rs OUTLETS
-SWITCHES- 10.00/1.00
N/A� /� 77
/ Cic. cd 7 LIGHTING FIXTURES 10.00/1.00
,
ADDRESS RESS O 's APPLIANCES-RESIDENTIAL 4.00
PHONE 7 ^ PANELS. 10.00 DATE OF APPLICATION
IT C
ARC T • • PLAN CHECK FEE P.C.NO.
GR N/rL ` PANELS IOVER 200 AMP) 20.00
ENGINEER
uc.ND. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 20.00
APPPPLIICANTS MOTORS SEE FEE SCH.
/ v
'� �/`�• � (' / SERVICE CHANGE 20.00
woo LIC"IiNS�1)CONT RACTORS DECLARATION TEMP.POLE 30.00At
S'
¢ u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
wa N (commencing with Section 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 CIa s I.ic.Nwnber
O z pate COntmetor
< y s BUILDING PERMIT
¢ ¢w OWNI!R-BUILDER DG fG INFORMATION
E
5 a y I hereby alfirm that Lam exempt from t e Comwelor's License MISC.- REFER TO ORD
3 u y p VALUATION $/FT.
r .. O < Law for the following reason(Sec.703L5.Business Professions PERMIT ISSUANCE 10.00
Code:Any city or county which re<luiresa permit toconstruct,alter,
QQ improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
¢ requires the applicant for such Perini t0 file a signed statement that TOTAL PERMIT TO
w mhe is licensed pursuant to the provisions of the Conlrnclors License
A
Luw(Chaptcr,9 lcrommencingwith Suction7000)of Diviston3ofthc
io Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE L
o the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
to
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER IEA.15.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cop pm¢alion,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 Conlmew,'s License I.aw docs not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S0,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.IC however,the building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not huild or im- BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB one•
❑ I,as owner ol'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 Profit siona Coda:The Commcmr's License Law docs not apply
to an owner or property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts forsuch projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANtTARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iamexemptunder Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I heohy infirm that 1 have a certi0eal,of consent to all-imsme. TONING
ora cerlificale Of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercuf(Sce.3800,Lab.C).
Policy No. Company�Lls.A •���c��
O ❑ Certified copy is herebyfu((niched, • FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified m y is fled with Ric city inspection division. MISC.- REFER TO ORD.
O Applicant_iY❑ N❑ Y ❑ No
~ m NTI!O- -SNS PERMIT ISSUANCE 10.00 (� FLOOD ZONE A.L.II.C.
� CIiRTI 1CA?I:ON AI:I N INS 'ROM WORKERS' -
W � COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.NO. pLG.
0. Cl( This section need not be cop pleled if the permit is Im One TOTAL Y❑ N❑ Y [:] NE]
hundred dollars(S I DD)or less)'
U O 1 certify that in the performance Of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL U mil is issued.I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,alter....king this Certificate of Ex-
F ? enption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you unisl forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agencv for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 performance MICROFILM
of the work for which this permit is issued(See, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
/ I cerllfy that l have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and countyPLUMBING 'LO
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 ��
hereby authorize represenlalives,of this city to enter upon the BOILER-COMP (Corr Ioo.o00BTU)SEE FEESCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against lir 'es,judgments, costs and expenses which CONST.TAX
may in y way ¢rue Batt said City in consequence of the PERMIT ISSUANCE 10.00
gmntin f this 11 mil. MECH.CONT. LIC.NO. MECH.
/ `� TOTAL TOTAL
Si p' a t c r ale
INSPECTOR COPY