09708 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BGILOING APPLICATION & PERMIT
X
ADDRESS iosos- til 09700
t BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S • PLAN CHECK VALIDATION
�/\ NAM�E�[ Ot( TY. ELECTRIC PERMIT FEE
C
SITR ACTORi R S S w% PHONE r 7. 1 1'1
NOME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO LIGHTING FIXTURES 10.00/1.00
ADDRESS caDR's
AAPPLIANCES-RESIDENTIAL 4.00
1ORE5
PHONE PANELS 10.00 DATE OF APPLICATION
OR
CHIrECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE .C.NO.
ENGINEER
•LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG SPECIAL CIRCUIT 15,00 PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.000 yr p/
o o LICENSED CONTRACTORS DECLARATION TEMP.PALE 30.00
¢ o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BL
Q N DG. ELECT. PLG. MECH.
r D Z Professions Code,and my license is in full force and effect. _
Z oy - License Class Lic.Number .t, El ® 0
9 Z Dole Contractor
a y f BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a o 0 0 INFORMATION
St
; H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
IN u. o sr Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION
Ew Code;Any city or county which requires a permit to construct,alley,
¢ ¢ ¢ o improve,demolish,or repair any structure,prior In its'nsuancc,also ELEC.CONTR. LIC.N0. ELEC
wG a require,the applicant for such permit to file a signed statement that - TOTAL / �O PERMIT TO
$w he is licensed pursuant to the provisions of the Contractor's license
FZ > Law(Chapter 9(commencing with Section 7000)of-Division 3 of the
E 4 o Business and Professions Code)or that be is exempt therefrom and CITY. PLUMBING PERMIT FEE
,¢ F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s- ;`0 by any applicant for a permit subjects the applicant lou civil penally
of IT of more than five hundred dollar,(S500f): ALTER-DRAIN& VENT-WATER (EA.),5.00
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do lire work,and the structure is not
intended or offered forsale (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 Vr Improves thereon and who does Sncll work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve _
met,are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-I INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im RES IND CON PB Omar
prove for ppo
urse of sale.). INDUSTRIAL W ASTE INTER. 30.00
❑ 1,as owner of the property,any exclusively cOptmctimg with ❑ ❑ 0 0 11
licensed contu'etors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of propery who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA,200fi/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt tinder Sec. ,B.&P.C.tiyr this WATER HEATER W/VENT 6.00
rcasun
Owner n xc�f- WATER SYSTEM 5.00
l,�. J ACG GATE ACC.FILE NO.
�Lpc : S Co�51 t.,-r6,UEtLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm.lhul I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified s
copy(hereof(Sea 3800,Lab.0.).
Policy No. Company
U ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T]4
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant YE] N� y � N�
~ w PERMIT ISSUANCE 10.00
M CER'I'117CA'I'li OP EXIiM PILON FROM WORKERS' PERMIT ZONE A.L.u.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG,
� N� v � N❑
CL z (This section nlied not be completed if the permit is.for one TOTAL
v
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 F mil is issued,I shall nut employ any person in lin,manner so as to
U beannc subject to the Workeri Comperovlion Laws of Culifunda.
W Date Apphcant ALTER OR ADO TO MECH. 5.00 BUILDING
>_ rn NOl'ICF- 10 APPLICANT: If,after making Nis Certificate of lix-
2 empt ion,you Should become subject t0 lye Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirmthat 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.0.). I 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
/ I cerlify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction. and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to mer, indemnify and keep barniless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting Of this permit. MECH.CONT. LIC.NO. MECH.
\ / f/S- DTAL TOTAL
Signature of ApplicAtIContractor Dale
INSPECTOR COPY