09675 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
9 _ BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 967
OWNER'$ / PLAN CHECK VALIDATION
�y NAME ^^��t QTY. ELECTRIC PERMIT FEE
ONEL
NAVEflACTOR UTLETS-SWITCHES-RECEP 10.00/1.00 1'
MM 1T VCR LIC No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS f1/I
SS „` ONE - PANELS 10.00 DATE OF APPLICATION
ADflRCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER ,.�---
uc.No, SIGNS TRANS. 3.00
ARC H.OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
-_ ZIP EMP.METER OR POLE INS. 20.00 l'.f
Ar5
ADDRESS MOTORS SEE FEE SCH.
DOREss
SERVICECHANGE 20.00
w o o -LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �l/(f 41
< i w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m i Professions Cod and my license is in full force and effect ❑ ❑ ❑
2 o m - License Class Lic.Number�(A.I�
4 z - D Data �j` p-QC Contractor=:--
OWNER-BUILDER
ontractor= -
M Z - J
m s J BUILDING PERMIT
ao re 4re u OW'NIiR BUILDER DECL.\RA'T'ION INFORMATION
X 3 LL w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD -
a, u o so Law firz the Billowing reason.(Sec 7031.5,Business and Professions 'PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or County which requires a permit to construct,alter,
oimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D LL requires the applicant for such permit t0 IIIc a Signed statement that TOTAL
w m he is licensed pursuant to the provisions of the Contractors License PERMIT TO
H z r Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE 11�elw O L)E L
ec I- tile Iwss far till'alleged exemplion.Any violation of Section 7031.5 STORIES TYPE CONSTR.
m
a- 3 - by any applicant for a permit subjects Ilse applicant to Civil penally
.fact more titan five hundred dollars($500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their rile conmarelmu n,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 --
Code:The Contractor's License Law does not apply to An owner Of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such inlprovc-
mentsarenotintemdedoroffered forsale.hhhuwever,thebuilding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion. - . - .
the owner- GAS EASYSTEM OVER 4 (EA) 2.00
builder will have the burden of proving that he did not build or am BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ I,as owner of D@ property,am exclusively contracting with . .
❑ 0 ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'The Contmmor's License Law dues not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a coniractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Coal...IDr i License Law. TRACT NO. PARCEL NO.
.L❑ I am exempt alder Sc,.-,Is&P.C.I'ur thin
reason WATER HEATER W/VENT 8.00
Owner'r Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSATICIN DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
-�, copy thereof(Sec.3800,Lab C.).
Policy No sr.Jf I1Y Fl3fmpany��' 17` yit'a
O ❑ Cer then copy is hereby fu hhc .
F OL1 ¢rtlhu7» yT ' -Ofd tth th• ly ecth, div Ion FIRE$PRINK ENERGY T-2d
Apphcahi �� ✓+-- o �� oma MISC.- REFER TO ORD. YE] N0 YE] NE]
N CER'11FICATIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPIi rmit NSA1'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ ❑
CL 0 (This section need nut be Completed if the peis for one TOTAL N
hundred dollars IS 100)or less.)
U O I certify that in ilia performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U nail is issued, 1 shall not employ any person in any manner so as to
O W become subject to the Workers Compensation Laws of California. n,
Dale Applicant BUILDING V L/
D- ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making ork rs'Cor ale sa Ex-
f'- ? eovisio,you should become subject to the Workers'Cu Melly lion APPLIANCE 5.00 PLAN CHECK
provisions io the Labor nit that
you must forthwith comply with Z
U such provisions or this permit shall be deemeJ revoked. AIR HANDLING UNIT(TO JO,000QF:M.) 4.00 FEE (a _
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.F.M.) 6.00 SEISMIC FEE f7)
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read This application and state that the abuse VENTILATION FAN (SINGLE) 4.00
• information isstate l I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
slate
ordinances and laws relating to bulldog Construction, and
hereby authorize representatives of this city es enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
riz properly for inspect of
i purposes.
(We) agree to save_ indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against li hies,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
maygl�g�uwgmn,.!11 City in consequence of theBing MECH./ - TDTALTOTAL 9 ��,� Signa re Conime Date
INSPECTOR COPY