09649 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGADDRESS APPLICATION & PERMIT _ X9649
ADDRESS
MIS I BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'$ PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
v PHONE S J_/�
NAME acTORs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No, LIGHTING FIXTURES 10.00/1.00
ADDRESS TOR's PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 1Q.QQ DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.0 N0.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
Lac.NO, SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.gq
APPLICANT s MOTORS SEE FEE SCR.
SERVICECHANGE 20.00 /ry Q ,("/
o o LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 '✓ d/U J
c I, u I hereby affirm that I um licensed under provisions of Chapter 9
N a ac (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
r y z License
Professions Code,and my license is in full force unA effect. 1
o i m o License Class Lic.Number
y ti w Date Contractor
Q f
¢ 0 w a OWNIi R-RUILDIiR DECLARATION BUILDING PERMIT
wLL m I hereby affirm that I am exempt (ruin the Contractor's License MISC.- REFER TO ORD INFORMATION
u o ¢ Law for the t'ollowin•reason.(Sec.7031,5.Business and Professions MA WATION S/FT.
- < s PERMIT ISSUANCE 10.00
E 14Pf Code,Any city orcounty which requires a permit In construct,alter,
ac
a 0 improve,demolish,or repair any structure,prior to Its Is9lance.also ELEC.CONTR. LIC.NO, ELEC.L
ec A c LL requires tile such e applicant for ch perm it to file a signed statement that
w m m he is licensed pursuant to the provisions of the ContractorTOTA
Contractor's License PERMIT TOC
r z Q
Law(Chapter 9(com omemg with Section 7000)of Division 3ofthc /�
n O Bushes and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE V' 41 A1_)67'1 0
m .m the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
as
by any applicant lbr a permit objects the applicant to a civilpenalty
of not more than five hundred dollars S500)): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,$s owner of the property,or in, employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the slructim is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
property Who builds Or improves thereon,and who does such Work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
menu are not intended or offered for sale.If,howeveq the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owncr-
builder will have the burden of proving that he did not build or ice- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of late.). RES INDUSTRIAL WASTE INTER. 30.00 ElI❑ ❑N 1:1OOr
ND
Clo
I,as owner of the property',am exclusively contracting with
licensed contractors to construct file project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Cont rector s License Law dues not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a coluractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
-reason WATER HEATER W/VENT 6.00
Owner Date$- WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKHRS' 0MPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ca-consent to self-insurc,
or a eertilicule of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereoffSec.3800,Lab.C,L
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z . ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-24
H O Applicant MISC.- REFER TO ORD. V❑ N V ❑ N❑
M w CERTIFICATE of;EXEMPTION('ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.N0. PLG.
ClCL This vection reed not be completed if the permit is for one TOTAL Y N V F N
::k Z hundred dollars IS 100)or Icss.)
U O 1 certify that in the performance of the work for which this per- QTY, MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers Compensation Laws of California.
Dote Applicant BUILDING
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 Q a S
F 2 4mplion,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000OF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10M)CF.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(he 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 HEATI NG UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is corral 1 agree to comply with all city and county PLUMBING
ordinances and state laws retailing to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby incithentioed roperty for ins of this city LLr enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property torinspc of
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gr g of this permit. MECH.CONT. LIG NO. MACH.
0-A S TOTAL TOTAL
Signa o Applicant/ n etor
INSPECTOR COPY