09641 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
j I ADDRESS '
'�k \ BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 09641
OWNER'S PLAN CHECK VALIDATION
/ NAME -QTY. ELECTRIC PERMIT FEE
• PHONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 70.0011.00 QQ
LIC,NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4,00
PDDRE55
�. y PHDNE - PANELS 10.00 DATE OF APPLICATION
OR PANELS PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
1`�iC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. ''11 SPECIAL CIRCUIT 5.00 .. PER MIPVALIpAT10N
iA R lt'- [o- zip EMP.METER OR POLE INS. 20.00 r
APPLICANT MOTORS SEE FEE SCH. / J
A
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00' {j
W.u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCEaDATE
(commencing with Section 1000)of Division 3 of the Business and
¢ w SLOG. ELECT. PLG, MECH.
F. y z Professions Code,and my license is in full force and ef(Cd. ❑ ❑
a Dm tf u License Class _ v �Lic. 2
4 Date � -:1 V5Conimctor
�s
E-1 ❑
BUILDING PERMIT
rc anW
n U CNER-BUILDER DECLARATION INFORMATION
�w g LL H I hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD
coo, Low for the following tea se n.(Sec.7031.5,Besinessand Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which reyuiresa permit to cunstrucl,alter,
Q ¢ 4 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO ELEC. J� ,rte
ea
wG¢ requires the applicant for such permit to file a signed statement that TOTAL TQ y= PERMIT TO
m o Ile is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe y-
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE `� (✓'� I
f E o
¢ H m the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty��. ALTER-DRAIN&VENT-WATER (EA.) 5.00
.�" of not more than five hundred dollar'($500).):
❑ I,as owner of the property,or my employees with were'as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES UNITS
intended or offered for sale (Set. 7044, Business and Pro&.., its DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code The Contmetor's License Law doe'not apply to an owner of -
Property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP - 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
merits are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 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 im. BUILDING USE
prove for purpose ofsale.): INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
13I,as owner of the property,am exclusively'contracting with El 0 El 1:1 0
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 a contmctons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l and exempt under Sce. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reexm
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG.FILE NO,
WORK IiRS'COh1P1i;ISA'fION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a ce eate of consent Insure
or a certificate(See
Workers' .C.). tlo� ltr 'a Clrfl
ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.l. e ♦ Q
Policy Ntfi1S5�l�� Q41Q,u�y
Q Certified copylsh Tchj'furnished. FIRE SPRINK ENERGY T-24
z.Z ❑ Certified co y is Ele with tl city inspection division. MISC. REF ER TO ORD.
O Applicant YE] N[J Y 0 N[D
w� C17RTIFICATI:01:EXEMPTION PROM ORKERS' PERMIT ISSUANCE x10.00 PLooO ZONE AL.U.o.
LU 5 COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG,
CL 0 IT his Section need not be completed if the permit is for one TOTAL Y❑ NE] Y E) N
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
U W become subject to the W'orkeri Compensation Laws of California.
D, . Date Applicant BUILDING
>_ w NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F 2 eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith-comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10JJOOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 'SEISMIC FEE
I hereby affront that dere is comiruaion lending agency for EXHAUST HOOD (WITH DUCT) 5.00
(le 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 HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state Ren"he above VENTILATION FAN (SINGLE) .;4.00
information is correct.1 agree to comply with all city and county PLUMBING
oNinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city toenter 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in ......coupe,of the
granting of.this permit( y MECH.CONT. LIC.NO. MECH,
�''CR-� TOTAL TOTAL
XSignature oT Applicant Contractor r Date
INSPECTOR COPY