09598 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NGPROJECT I DENTI FICATI ON PERMIT NUMBER
aUILDING APPLICATION & PERMIT
aooREss 09599
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
D ��q� PLAN CHECK VALIDATION
N ME C q!c.'/ QTY. ELECTRIC PERMIT FEE
PHONE '7, h- /7•�J�
NAMER C Rs C51 UTLETS-SWITCHES-RECEP 10.00/1.00 / / (((///
l LIc�.�E?��f/ LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
aDOR E55 APPLIANCES-RESIDENTIAL 4.00
1�O )/,/fa Ave /d rG�
Y /`•��P AEE�Y PHONE PANELS 10.00 DATE OF APPLICATION
F CT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
uc.ND. SIGNS TRANS. 3.00
ADDRESS 1. rAMQE7V/jam. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 20.00 _ J
PLCAaTsygp / E MOTORS SEE FEE SCH. /CLF-w-•.�/
ADDRESS
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
o o
QU o I hereby affrn, flirt I mil licensed under provisions of Chapter 9 ISSUANCE DATE
y G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. p
F w Z Professions Code and my license is in full force and effect 1!
z o m- License Cla Lic.Number
w r w �Convact�f INFORMATION
I
BUILDING PERMIT
¢ ¢ a
OWNER-BUILDER DIiCI. RATION
¢o n v S'
w ; y I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD
-
r LL O J Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 ( VALUATION $/FT.
E �> E Code:Anycily orcounty which requiresa permit toconslruct,alter, n
¢ ¢ a o improve,demolish,or repair any structure,prior to iL issuance,also ELEC.CONTE. LIC.NO. ELEC. ) /
n
o a req aims the applicant for Such permit to the a signed statement that UI TOTAL p MIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
E, r O the basis for the alleged exemption.An
m g p ' heapplicnt to a cion malty STO 5 TV CONSTR.
w. 5-: by applicant fire permit subjects th500).)cam loa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of nal more than five hundred dollars(5500)J:
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW 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 ProfessionsDRAINS-FLOOfl,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 dues such work FIXTURES-PER TRAP 5.00 50.RT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such'in
prove-
meals are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or
r
improvement is sold within one year of completion,the owne
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.)' INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Other
LD 1,as owner of the property,am exclusively comractiag withEl El 0 El
Mnsed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 00 ASSESSORS NO.
Professions Code:The Contractor's 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.
❑ 1 am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
Drawn
Owner ^/ L2yyI Uate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W-4�tiIPI 0 C(7R1PE;OSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent In self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,nr a certified
c reof(Sec.3800.Lab.C.I, _
` O olicy o. Company /
1 led copy is hurcby t s
Z Z� Q� Cerife 'tpy is Ill d with L u 'ily in p lir tl ision. FIRE SPR INK ENERGY T94
F O�' Anhlicant MISC.- REFER TO ORD. v � N� v � N�
Cr to CERTIEI ATE OP FNIP ION h4ON1 WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
�++d O fl'his section need not he completed it' the permit is for one TOTAL V❑ N YF N
Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California. '
i Date ADD TO MECH. 5.00 Applicant BUILDING r-)O
>_ to NOTICE TO APPLICANT: If,atter making this Certificate of Ex ALTER OR
F Z_ ouptiom you should become subject to the Workers'Compensation 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 10,000C,F.M.) 4.00
CONSTRUCT TON LENDING AGENCY AIR HANDLING UNMOVER 10p00GEM.16.00 SEISMIC FEE
1 hereby uffirai that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work 1'or which this permit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT IT 100,000 B.T.U.) 8.00
'Lender's Namctoo HEATING UNIT(OVER 100,000 B.T,U.)9.50
Lender'x,Addre« _ ELECTRIC
Icert"ll�ao`llave read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information n islae.. I agree to comply with all city and county BOILER-CDIVP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state.laws relating w building construction. ant
hereby authorize ropersy Olives ec onflucity m eater Imo^ the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. /
(We) egret to save, imdenmify and keep harmless the City of 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 0.00
granting of this per it MECH.CONT. CIC.NO, MECH.
TOTA TOTAL (p�
at o p an .on a t Date �,
INSPECTOR COPY