C09707 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POIXT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AODDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
09707
R
PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• ONE
NOME °Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
Pol¢"tk- 13U1LAEA2S
Lnc.No.�l LIGHTING FIXTURES 10.00/1.00
C N RACTOR's [' PPLIANCES-RESIDENTIAL 4.00
ADDRESS tC Lj S. So,�P r SU�b+• �O
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CNECK FEE P.C.NO.
ENGINEER
IAC.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ASANTS
ADDRESS
MOTORS SEE FEE SCH.
S
' SERVICE CHANGE 20.00
F o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ cwi o I hereby affirm flat I an,licensed under provisions of Chapter 9 .1 ISSUANCE DATE
y "' (conumencimg with Section 7000)of Division 3 Of the Business and
4 (BLDG. ELECT. PLG. MECH.
F m i Pnlfesaions Code nd In1y license is in toll fore•and effect ❑ ❑ ❑ ❑
z o o, - License Class�Lia Nanother L4 I V Sus T
C H �� Date r+1- IN Contraclor
a Y f BUILDING PERMIT
¢ ¢O i sr OWNER-BUILDER DECLARATION INFORMATION
w3 LL I hereby affirm th I I am exempt from the Contractor's License MISC.- REFER TO ORD
Seo¢ Low for lire followingmason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
L - Code:Any city orcounly whichreyuiresapermit to construct,alter, �i )7{ �
Qm P 1 y Prior to its issuance,also ELEC.CONTR. LIC.NO. /J O/
¢ 4 improve,demolish,inn air an structure,I ELEC.
ar
U.
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
F7
m he is licensed pursuant to the provisions of the Contractor's License ,/ /
Fri
Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe S/l L /(:y
4 Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE 7
f i Q
¢ r o the basis for the alleged exemption.Am,violation of Section 7031.5 STORIES TYPE CONSTR.
d35 by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
O I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their 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:Toy 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 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intendedoroffered for sale.If.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have(lie burden of proving that he did not build or m- BUILDING USE
Provefor purpose cfsalc.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Omer
❑ I,as owner of the property,and exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 Contractors License Law does 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 it coneaclorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 .
the Contractors License Law. TRACT NO. PARCEL NO.
❑Cz am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason-
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
is WORK iKS'COMPFNSA'TWN DECLARATION WATER TREATING EQUIP. 5.00
1 Imreby affirm that I have it certificate of consent to sell-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy there,f e'.3 0.L.h.0 ..
1411icy Nm ompany
Q Q Certs lied copy is heeeby furnished. FIRESPRINK ENERGY T-24
Z 2 ❑ Certil'1k-d o is IILd with city inspeCction division. MISC- REFER TO ORD.
O Applicant '( I • �y•EI 111rs•I�y Y❑ N❑ Y ❑ N❑ .
c y CI:K"fll7ICA1'1:OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD zorvE A.Lu.c.
L COMPHNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ + v ❑ N❑
CL (This Section need not he completed if the permit is for one TOTAL
hundred dollars(5 100)or less.)
U O I certify that in the performance of tire work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit 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. /Date- 171y DApplicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: IL she,making this Certificate of Ex-
f- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with 7
U such provisionsor lhispermil shall bedeemed revoked. AIR HANDLING UNIT(TO I0=CF.NL) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE r S�
I hereby affirm that there is a construction lendingagency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the 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
Lender's NamAddress HEATING UNIT(OVER 100,000 B.T.U.)$.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) „i 4.00
• information is correct.I agree to comply with all city and county PLUMBING
ordinances and stat, lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the
shove-mentioned property for inspection BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
purpoms.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iiahilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
giantin,Of this )to MECH.CONT. LIG NO. MECH. -
TOTAL CW
TOTAL
Q-�1-k 7
Signature of Dote
INSPECTOR COPY -/
' I