09521 APPLICANT TO FILL IN INFORMAT ON WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[F I CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AooREss Hc- _ 0 9 5 21
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ��' . - PLAN CHECK VALIDATION
NAME �'I Q"1 OTY. ELECTRIC PERMIT FEE
Otdon
CON ONE o I
NAMETRACTOR s UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
rorureacroRs PPLIANCES-RESIDENTIAL 4.00
ADDRESS r
I PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT I
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
OR
O
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ARCHE 65 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAJ
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 AUG 23 1900;5
M o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o U I hereby affirm that I am licensed under,provisions of Chapter 9 T.'1 5QAIJPB
z w
(commencing with Section 7000)of Division 3 of the Business and FA a e. �� ^ BLDG. ELECT. PL MECH.
H w zo Professions Co a h license is I.,full force t f 1, ❑ ❑
z o,� - License Cla - Lia Number -
9 w o Date Contractor
BUILDING PERMIT
.ar ¢ a OWN IiR-BUI LDFR DECLARATION
o a U. INFORMATION
X S LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o j Law for the following reason.(Sec.7031.5.Business and Professions pERM1T ISSUANCE 10.00 VALUATION S/FT.
� - Code:Any city or county which requiresa permitmconstruct,alteq
K ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
amu requims the applicant fur such permit to file a signed stalentunl that TOTAL P t MIT TO
w rs
he is licensed pursuant to tire ro
e pvisions of the Contractor's License
ea Z i Law(Chapter 9(commencing with Section 70000of Division 3 ofthe
F i ao Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H m the basis for the alleged exemption.Any violation of Section 7031.5 STO ES TYP CONSTR.
dam _ by any applicant for a permit subjects tire applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
.fire(more than five hundred dollats($500).)'.
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do tiretr
work,and the 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 BD.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve- (�
mems are through
ot or offered Or nemployees, rovided that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, theowner GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of piovmg that he did not build or inn' BUILDING USE
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Other
❑ I,as owner of 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 P,elcoinns Code:The Contractor's License Law does 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 contmclons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.05 0 TRACT NO. PARCEL No.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reasonto
Owner Date WATER SYSTEM 5.00 UT ACC.DATE ACC.FILE No.
WORK ERS'COMPENSATION DECLARA'f1ON WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insmn•' ZONING ENO.SITE NO.
or a certificate of Workers'Compensation Insurance or a certified
Copy thereof(Sec.3800,Lab C.).
Policy No. Company
0 CI CenduLd copy is hereby furnished. FIRE SPRINK ENERGY T 24
z � Certified. o yy 's -rrd vvi the city inspection drvision.
Fp A aplkam�_(vrQ�l fifLyl MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
OCT CERTFICA'1'17 OF EX EM PT ON FROM WORK ERS' PERMIT ISSUANCE 10.00 /U FLOOD ZONE A.L.u.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. P�OU Y❑ N Ely❑ NEICL CL 0 (Po
his section need not be completed if the Permit is for ne TOTAL O
Imadred dollars($100)ar Icss)
0 0 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
ED Due Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: IL after making this Certificate of Ex-
Z - emotion,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=47-F.M.) 4.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 performance of the work 1m which this permit is issued(Sec MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that,I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct I agree to comply with all city and county PLUMBING ems_
ordinances and stat, 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 100,0008TU)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 liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may 'n any y accrue against said City in consequence of the
gun i f Ih crit / MECH.CONT. LIG NO. MECH.
Z ld W-hIk TOTAL TOTAL
Sig reo pphcant/ o mrp., ate
INSPECTOR COPY
1