09691 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
D
ADRESSILDIN APPLICATION & PERMIT _ y b y I
t BUILDING -ELECTRICAL-PLUMBING-MECHANICAL O^^^A
O E 'S PLAN CHECK VALIDATION
NAME / DTY. ELECTRIC PERMIT FEE
• -ar r/.C✓11PHONE
CONTRACTOR
NAME _ UTLETS-SWITCHES-RECEP 10.00/1.00 60,
rn L/eG• UC.ND. LIGHTING FIXTURES 10.00/1.00
r-ONTr ACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDR SS n
PANELS 10.00
N DATE OF APPLICATION
A CHITECTPANELS (OVER 200 AMPI 2000 PLAN CHECK FEEP.C.NO.
OR
NGINEER
LIC.No. SIGNS TRANS. 3.00
o DRlESS ENa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rFEMP.METER OR POLE INS. 20.00
ADDRESNrs / AJC MOTORS SEE FEE SCH. Q/rs., rT�V-••T-
�n SERVICE CHANGE 20.00
w o o LICEI EU CONTRACTORS DECLARATION TEMP.POLE 30.00
M o U I hereby affirm that I am licensed under provisions Of Chapter 9 rNt ISSUANCE DATE
N n (commanemg wish Section 7000)of Division 3 oC the Business and BLDG. ELECT. PLG. MECH.
F w zO Professions Code,af�IId my License is in full force and effect
zo m - License Class_I--=L�L Lie.Number'9✓G� x
o w r w Uate 5 -8� Contractor �y:pUk 6-
¢ m el@t 4,t BUILDING PERMIT
¢ a w ¢ OWNER-BUILDER DECLARATION INFORMATION
K
LL F I hereby allinn that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
F U 0< Law for the following reason.(Sec.7031.5,BuslnCSS.Rd Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, /p
¢ ¢ improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. 17y63 ELEC.
A0 ¢ regains the applicant for such Permit to Elle a signed statement that TOTAL y/,OO PERMIT TO
re w m re he is licensed pursuant to the provisions of the Contractor's License
Hz ¢ Law(Chapter9(c.nurcmingwith Section 7000)oflAvisien3.1the EL�G7
Itusinew and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE r
ce H O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
iF by any applicant for a pe nn it subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than I ivc hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages 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,AREA,COND. 5.00
Cade:1'he 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.rT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such'in
buildi e-
mentsarenotirlt®Wedor employees.provided
that such
budding 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 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIALWASTE INTER. 30.00 RES IND. CON PB Omer
0 1,as owner of 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 Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.2001[/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Ilan exempt under Sec. .B.&P.C.for Ibis WATER HEATER W/VENT 6.00
reawIT
♦ Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPBNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby ufllrm that I have a certificate of cotsenl 10 scbGinwrc. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or u certified
copy thereof(Set.3800,Lab.CJ.
Policy No. Company
O ❑ Certified copy is hereby lumiahed. FIRE SPRINK ENERGY T"24
Z Z A, Certified copy is Filed with the city inspection division. MISC.- REFER TO ORD.
O Apphcanl - Y❑ N❑ Y ❑ N❑
~ vr PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU CfiR1'IPICC0Ii OFEXEMPTION FROM WORKERS'
UJ � COMPIiNSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
CL Z ('Phis section need not be completed if the permit is for one TOTAL Y❑ N
N❑ Y❑ ❑
hundred doll...IS 100)or IessJ
U O I certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
LU Dale Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE: '10 APPLICANT: If,after making this Certificate of
Fz mnption,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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a constrdetion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,-Cie
C'ancc ul-the work fqr which this permit is issued(Soc. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Laine..Nam`
Lellde!a Nddrl' HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
66
1 cerlify that 1 have read thisapplication and state that the above VENTILATION FAN (SINGLE)" 4.00
• inBOILER H.P.or 100,000 B.T.U.) 6.00
formation is correct. I agree to comply with all city and county PLUMBING
ordinances and and nate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. _
(We) .gree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
tp� TK any way accrue against said 'ly in onsequence of the PERMIT ISSUANCE 10.00
grant gof this permit. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
pplicantlComonctor Date
INSPECTOR COPY