09639 (3) I APPLICANT TO FILL IN INFORMATION WITHIN•RED LINES - USE 13;L&P'OINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
ADAPPLICATION & PERMIT
DRESS ^�n
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
PHONE
HOME nCT°es UTLETS-SWITCHES-RECEP 10.00/1.00
411AC.No. LIGHTING FIXTURES 10.00/1.00
r, NTRAcrors u
ADD APPLIANCES-RESIDENTIAL 4.00
r ss . q �f
PHYONE `"3 / PANELS 10.00 GATE OF APPLICATION
Oqc ITccT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
ENGINEER
LIC.-NO. SIGNS TRANS. 3.00
ADDRESS ENG
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00 ,
ADDRESS rs MOTORS SEE FEE SCH. .I
f
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
•y, a u u •1 hereby affirm that 1 am licensed under provisions of Chapter 9 _ ISSUANCE DATE
r• w Q'N°-. (commencing with Section 7000)of Division 3 of the Business and .- `.BLDG. ELECT. PLG. MECH.
H � z 1 r fusions Code and m'license Is Ni full fur •I•- ❑ ❑ ❑
z o r`S, - I lren t. ess LI Number
o Z F,w. , Dat e Contr tor
�,,.a Y s '•'� an y - j:q, ); BUILDING PERMIT _
¢ a 9 1 OWN ERBUILDCR DI'CL-A' A110N '
¢ w v - - . INFORMATION
w ;A y I h r by u1'fi: that I en exempt h, theC ntra On's License MISC.- •REFER TO ORD
VALUATION $/FT.
H .. o st , L w for the following reason.(Sec 7031 5,Hus n s Ind Protessions PERMIT ISSUANCE 10.00
V,y Code:Any city.,coumy whichre,cinisa pe nm ht to co'nxtruct,elteq
¢ Qat improve,demolish, repair any structure,prior l0 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- 0 u requires the applicant for such permit to file a signed sletement that TOTAL PERM T TO
A w m he is licensed pursuant to the provisions of the Contract G��'s License
F z a Law(Chapter 9(commenCog with Section 7000)of Divisfdn3ofthe C
E 4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F m the basis for the allege)exemption.Any vitiation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicantfor a permit subjects the applicant to.civil penalty ALTER-DRAIN -WATER (EA.)'5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wnNcs as BACK FLOW PROTECT. DEVICE.:, 4.00 OCC.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,AR EA,COND. 5.00
Code:'Phe Contractor's License Law docs riot apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 5°.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
menlsare net intmWed isOwne@reoyee,,sale.lfed that inhebuilding GAS-.EA.SYSTEM-11NC.4OUTLETS 8.00
nr 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 n.1 build s int. BUILDING USE
f prove t'of pmm.ol'salo.l. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Om.,
❑ I,as owner.f the property,am 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 Cade:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contrectons)licensed pursuant 10
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1'am exempt under See .BAP.G for this WATER HEATER W/VENT 6:00
reason
Owner Date WATER SYSTEM 5.00 '`i ACC.OATE ACC,FILE NO.
WORK BRS'CO.MPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1+
I hereby War. tlmt I have a cerifienic of c rent to,el Ginsure. 6
or a certificate of Workers'Compensation Insurance,or a certified ,..1 ZONING. ENG.SITE NO.
opy th roof(Sc 3800-La . .)�1 1.,Ayw' e
hcy No Company-�jq;&pq $ -_'
0_ v-,. ,Intel copy hereby furhtshvd' k FIRE SPRINK AENERGY T24
Z .R
plfl ui s filed It m y Inspe't io dly, ivision. MISC.- EFER TO ORD a vY N� Y NEI\ppbLgnt - I.
cc C 14 .�i E.X PERMIT ISSUANCE 10.00 v
, � C; A 1 EX; 1PTION FROM WORKERS' FLOOD ZONE A.L.U.C.
LU > x .4 -COMPENSATION INSURANCE , PLG.CONTR. LIC.NO. '.;PLIC
a Z (Phis section need nut be completed if the permti it is for one 'TOTAL ••rh„ Y ia Y El ,N�
hundred dollars IS 100,or level
U O I certify that in the performance of the work lot which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U out is issued,I shall not employ any person in any nhx lnher so as to
become subject to the Workers'Compensation Laws of California. '
U.1 Date Applicant ALTER OR ADD TO MECH. 5.00 a BUILDING
} to NO'T'ICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
t0• Ihe97,C, ince .f the work for which this permit is issue)(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)Lender's Names ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
• in Wrndlion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting ofthis permit. MECH.CONTwjr�� LIC.NO. MECH. ,
GG•.00 TOTAL TOTAL
Signature of Applicant/Contractor Data Abd
INSPECTOR COPY '
fi.AFM1+�H. ..