09686 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
4 Q 2 Cr, BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9686
OwNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRICPERMIT FEE
1 orvE
NAMERAGT Bs OUTLETS-SWITCHES-RECEP 10.00/1.00,1+6
-PL-\ Iy
Y / O. W 3 LIGHTING FIXTURES 10.00/1.00 d "`_
LIC.N
CONTRACTORS
ms
ADDRESS
PPLIANCES-RESIDENTIAL 4.00 W
tfgh ` LINI . PHONE :�L. PANELS 10.00 l DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
saNZoSc sI�3
ENGINEER
LIC.No SIGNS TRANS, 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00 -
APPLavANTs ? MOTORS - SEE FEE SCH. w R
ADDRESS
SERVICE CHANGE 20.00 / /9/��
w 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Fu w I hereby affirm that I am Iicenu l under provisions of Chapter 9 fi ISSUANCE DATE
a > ("ommencing with Section 7000)of Division 3 of the Business aPit BLDG. ELECT. PLG. MECH.
H m i Professions Code., pC&ay lice nu is in full fo nI� K ct ❑ ❑ O
Z, o m - Li cense Class CC.. 1I UU Lic.Numbe 3
o y H ° UIne-r"7'Et-8§ Contractor
a x O BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
A 0 a J a INFORMATION
X g " y I hereby'affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL u_ oa Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 r/1 VALUATION $/FT.
Code Any city or county which requiresa permit to construct.alter, O
a ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
D m'
¢ requires the applicant for such permit to file a signed statement that TOTAL q V3 PERMIT TO
A w $" he is licensed pursuant to the provisions of the Contractor's License
La.(Chapter 9(commencing with Section 70001o(Division 3 of the �L 6C �
4 c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE r
'the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty.
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as ownet of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not
intended or offered for sale(See 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 does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
. meats are hot hrough
ownemployees,for sale.
If.ed that however,
thimprove- GAS-EA.SYSTEM-1 6.00
meats are not Intended or offered for sale.IC however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ El El 13
licensed contractors to cureJiuet the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
mW Professions Code.:The Commeliah License Law does nal apply
_ to an owner of property who builds or improves thereon.andwho- LAWN SPRINKLERS-OVER 5 (EA.( 1.00
contracts for such projects with a contractors)licensed puisuunl to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,tl.&1'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK P:RS'COMPENSA NON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a celtificate ofconsent to self-insure:' ZONING ENG.SITE N0.
or a certificate of Worker,Compensation Insurance,or a certified
copy the SOq I-ub.C.l05( ,.x301 T3-�
Policy Company-W.Ld+ .7
O Certified Copy is hereby famished. FIRE SPRINK ENERGY T-24
Z Z I Certific cop is Bl.1 with he cit' ins eetion division. MISC.- REFER TO ORD.
Q Applicant Y N V NC]
~ rn PERMIT ISSUANCE 10.00
Lu - CERTIFICATE OP EXEMPTION ION
O TION PROM WORKERS' FLOOD ZDNE A.Lu.C.
W Need not
be voiN'INSURANCE PLG.CONTR. sec.No. PLG.
Z (This section need noI be completed if the permit is for one TOTAL
hundred dollars 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
LL I- 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.
Date Applicant BUILDING
>_ w NONCE TO APPLICAN'P It,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
r Z cmption,you should become subjeeVto the Worker,Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, y8n must forthwith comply with FEE
U such provisions or this permit`shall be deemed revoked. AIR HANDLING UNIT(TO 10,000O.F.M.) 4.00
CON'S'[RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
perfo
the rmance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ -"..��- HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address H EATI NG UN IT IOVER 100,000 B.T.U.)9.50 ELECTRIC /y N
I certify that I have read this application and state Olaf the above VENTILATION FAN (SINGLE). 4.00
information is correct. I agree to comply with all city anti county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon th°
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless 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
gr' 'ngo this permit. MECH.CONT. LIC.NO. MECH.
a TOTAL TOTAL
Petal Applica t ontramoP Uatc
INSPECTOR COPY