09596 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADORES$7 9Lr� -[ `� `�nn
' �+
v BUILDING -ELECTRICAL-PLUMBING-MECHANICAL On
c
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
A.J .�- PHONE
NOMERAcroR's 1. UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
NO.ESSsrons APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OF rtET - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00 1 �
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rFEMP. METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 p
woo LICIiNS1 D CONTRACTORS D17CLARATION TEMP.POLE 30.00
¢ i w I hereby afGnm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z, (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
0 y z Professions Code,and&i license is in full force and effect. BLDG. EA 1:1z O m- License Class[.�,p-L -Lic.Number �'n a G n
0 m Date Contruclnr ��
a x f �� BUILDING PERMIT
¢ ¢ w a OWNIi R-BUILDER DECLARATION
A ° a " MISC.- REFER TO ORD INFORMATION
X g LL I hereby allinn thm I run exempt from the Contractor"License
¢ OLaw for the lollowieg reason.(Sec.7031.5,Businessand ProfessionsVALUATION $/FT.
H - PERMIT ISSUANCE 10.06,-
-a
Code:Any city or county which requires permit to Construct,Act.
ecto ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Lc Law(Chapter 9(enomencing with Section 7000)of Division 3 crib,
¢ a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Sectinn 7031.5 STORIES 'TYPE CONSTR,
n3 - by any applicant for a permit subjects me applicant to a civil penally ALTER-DRAIN -WATER (EA.15.00
of not more than five hundred Told...($5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
Sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such impmve-
Inerts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or runBUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a comirewr(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
wm
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent m self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lab.CJ. � �
Policy No. m
Copa ('
ny yJ-J 4;?;g- �V w/t,
Q ❑ Certified copy is hereby furnished. FIRE$PRINK ENERGY TP9
Z Z ❑ Certified - It, is filed s'th the ci inspection division.
FO Applicant �-.�- MISO.- REFER TO ORD. v ❑ N V ❑ N❑
MN CERTIPICA'1'1701:EXEMPTION Ir ROMPORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CE. O (This Section need not be completed if the pern it is for one TOTAL Y❑ N❑ Y[:] N❑
0 hundred dollars IS 100)or less.)
0hu
U O I certify that in the performance of the work for which this per, OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mil is issued,I shall not employ any person in any manner so as m
U become subject to the Workeri Compensation Laws of California.
U ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE'1'0 APPLICANT': 11,atter linking this Certifica]e of Ex-
F- ? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tire Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 6.00 SEISMIC FEE
1 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(TO 100,000 B.T.U.) 8.00
Lender's Name
L,adcr's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply'wish all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00 r
hereby authorise representatives of
this city to enter upon the
inspection above-mentioned property forBOILER-COMP(Or 100,000 BTU)SEE FEE SCH. MECHANICAL hipurposes. ve0"V
(We) agree to Taut, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 d'e CONST.TAX
may in any way u,cron against said City in consequence of the
gruntingoltim,anndt. MECH.CONT. LIC NO. MECH.
agi - TOTAL �.� U TOTAL
DPI n rano Date
INSPECTOR COPY