6983 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AppRE55r 6983
IL) ( BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
PRONE -
i, NAMERAcroRs UTLETS-SWITCHES-RECEP 5.00/1.00 ,
%[ TIC.NO. 06 LIGHTING FIXTURES 5.00/1.00 y
CONTRACTOR 5 i APPLIANCES-RESIDENTIAL 4.00 5
�- A4IKC HONE1?7PANELS 5.00 DATE OF APPLICATION
aNCHITECi I SIGNS 6.00 PLAN CHECK FEE P.C.NO.
liMMn DR
ENGINEER
v uc.NO. SIGNS TRANS. 3.00
ADDRESS E"G SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT SMOTORS SEE FEE SCH. (\�17�"w/
ADDREDDRESSS
SERVICE CHANGE 10.00 1.7`
� 02 LICENSIi U CONTRACTORS DECLARATION J
Is u u I hereby u(Enu thin 1 ma licensed under proviyi.....of Chapter 9 ISSUANCE DATE
wa u (commencing with Section 7000)of Division 3 if the Business and BLDG. ELECT. PLG. MECH.
r N i lhofessioas Cagiyy,, ryqdI ntgIyy�y n full fore• fie t.
z o u, Li cense ClassLb_?•�JLNumber Lill
Q I-w Uatcf-J;- Contractor
sr ' " `�yR� BUILDING PERMIT
¢.a w< OWNER-BUILDER DECLARn'I'ION - INFORMATION
a oa 'a MISC.- REFER TO ORD
w 3 LL r I hereby infirm that I am exempn from ilii Contractor's License VALUATION $/FT.
F .. o j Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 /.,[�`�y
Code:Any city or county which requires a perm it to construct, ELEC.GONTR. LIC.NO. / /" -
a < �� improve,demolish,or repair any.struclure,prior to its issuance,also ELEC. /
O u requires the appliclnit for such permit to file a signed statement that ,TOTAL PERMIT TO
w w he is licensed pursuant to(lie provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ol'Division 3 ofthe N
Business and Professions Code)or that he is esmnpt therefrom and GTY. PLUMBING PERMIT FEE T �v
F a the basis for the alleged exemption.Any violation of Section 703 t.5 STORIES TYPE CONSTR.
dam by any applicant for a permit subjects.the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
in ended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'Plies Contractor's License Law does riot apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• hinuclf re throughhisOwnemployees.for sale.
If,hothut ever,such improve GAS-EA.SYSTEM-1 4.00
merits arc not intended or offered(or sale.If,however,the building
or improvement is sob within one year of completion' the - . .) _ .00 BUILDING USE owner- GAS EASYSTEM-OVER 4 (EA1
builder will have the harden of buil
proving that he did not d or im- RES IND CON PS Omer
prove for purpose ofstheJ' INDUSTRIAL WASTE INTER. 20.00 0 ❑ ❑ 0 ❑
❑ I,as owner of the property,am exclusively contracting with
np"d contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO,
Professions Code:I'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 t1
contracts for such projects with a contraetot(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 - TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.(o,lIuR WATER HEATER W/VENT 4.00
r.,mr
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARA'T'ION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy there ( 8 o;npm0 Lab.CJAr�, r-Drq z4 3C
Policy No ommb ylJa-�7-a7 .7 Y/I
❑ Certified copy is hereby l CERTIfj ATE.:01'1?XEth N N ld. FIRE SPRINK -ENERGY TY4
Z �� Certified47/co t is fie with the -ity it lesion divisor
A . MISC.- REFER TO ORD. Y Q NE] Y E] NE]
~ MIf m FROM WORKERS' PERMIT ISSUANCE 6,00 FLOOD ZONE A.L.U.C.
LU - COMPFNSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG. 141'
,/ v N Y N
CL 0 (This section need not be completed if the permit is for one TOTAL T
hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers''Compensation Laws of California. BUILDING � Sa
UJ
Uatc Applicant ALTER OR ADD TO MECH. 4.00
} 0 NO']ICI' TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit SULts¢%deemed revoked. AIR HANDLING UNIT(TO 1Q000QF.M,) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE �YO '
I hereby affum that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B-T.U.) 4.00
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I artily him I have mud this application and sL,te that the above VENTILATION FAN (SINGLE) 3.00
• inti ..union is correct. I agree to comply with all city and county
of and state laws relating to building construction, and BPLUMBING
4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property lot 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting ofthis permit ` MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signal pli rnctor1 Onto
` INSPECTOR COPY '
IA