9327 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
B°ILDING ^ APPLICATION & PERMIT
/
}( AODREss �Da9b locei-�&O fl Dr. __ 327\ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
OPHONE
eAntEA °R UTLETS-SWITCHES-RECEP 10.00/1.00
LC,No, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ons APPLIANCES-RESIDENTIAL 4.00
CODNTRAS
PHONE PANELS 10.00 DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ARCH.
oo Ess ENG' SPECIAL CIRCUIT 5.00 f vEEMlr VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID
ARMOTORS SEE FEE SCH.
ADDDDRESSESS
SERVICE CHANGE 20.00 JUL 1 � 198
0 2 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a ° I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA P o
(commencing with Section 7000)of Division 3 of the Business and
¢ u BLDG. ELECT. L .
H y i Professions Code,and my license is in full force and effect ❑ ❑ ❑
oz w t] License Class Lic.Number
H w H Date Contractor
a y E BUILDING P R IT
rc ¢ a OWNER-BUILDER DECLARATION
A o a u INFORM TION
La 3 LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uOa Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� -to Code:Any city or county which requiresa permit to construct.alter.
Kw¢ improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
u w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of me Contmcmi s License
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
f 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
CE H m the basis for the alleged exemption.Any violation of Section 7031.5 S S TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500),):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00
their sole compensation,will do the work,and the st mcftne is not OCC.GROUP REB.UNITS
intended or offered for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors 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 TOTAL ACREAGE
himself or through his own employees.provided that such impriwe-
memsarenotinlendedorofferedforsaa.'If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the minden of proving that h - . - . .
e did not build or im- BUILDING USE
prove for purpose ofsalc.). 7 INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omer
❑ I,as owner of 11/mproputly,am exclusively contracting with - 0 El- E]
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and 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 51.00
contracts for such projects with a contractogs)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
I xcmpt under Scc.-,B,&P,C.I'or Ibis WATER HEATER W/VENT 6.00
ase-
Own' Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
ff-
WO -RS'COMPENSATION DECLARAnC WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a cerlificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
' copy
thereof;Sec.3800,Luh.CJ,
Policy No, Coln Pany _
O ❑ Certified copy nher'by l urn ished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC- REFER TO ORD.
O Applicant Y0 N❑ Y NC]
CCN CERTIFICATE Ole EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1FLOOD ZONE AT.0 C.
Lu > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one _ TOTAL v N� Y C] N�
hundred dollms IS 100)or less,)
U O 1 certify that In the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL U mil is issued,I shall not employ any person in any manner s0 as to
O L) become subject to the Worker Compensation Laws of California.
y Date Applicant BUILDING
} to NOTICE TO APPLICANT: If after making this Certificate of lis- ALTER OR ADD TO MECH. 5.00
♦- Z 'mpti0n,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=C.F.M-) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that.there is aconstruction 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.). 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
ordinances and state laws relating to building construction, and BOILER-OOIv1P13H.P.Dr100,000B.T.U.) 6.00
hereby autlmrim representatives of this city to enter upon the ,g OI F__
R-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, in lenmrity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in y way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gmab f this per it. MECH.CONT. LIC.N0. MECH.
OTAL TOTAL
I at oflyp e I smnmlor Date
' INSPECTOR COPY