09664 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS APPLICATION & PERMIT 09664
16a.1BUILDING-ELECTRICAL-PLUMBING -MECHANICAL r
0
' OWN 'S PLAN CHECK VALIDATION
NAME OTY- ELECTRIC PERMIT FEE
DNE37 -040
INe AcroRs Q UTLETS-SWITCHES-RECEP 10.00/1.00
Q Cif-awl• LIC.Sd. "';p7'� 1 LIGHTING FIXTURES 10.00/1.00
TRACTORS PPLIANCES-RESIDENTIAL 4.00
Ftts
I VI 0 FHONEa ho4o0 PANELS 10.00 DATE OF APPLICATION
PANELS (OVER 200 AMP) 20.00 PLAN CHECKINEERuC.�C tP �7 )i SIGNS TRANS. 3.00
.OR ry . - r PERMITVREss SPECIAL CIRCUIT - 5.00 -
'� .,. /4 ZIP EMP. METER OR POLE INS. 20.00 SEP 0 51985
RESS MOTORS SEE FEE SCH.
PP
REss
V, Sliti v C / SERVICE CHANGE 20.00 �Ify�f CV
w¢ TEMP.POLE 30.00 Pertin
H 0 o LICENSED CON UECLA RATIO'
¢ u w I her,by uffinn that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H G H (commencing will Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r z Professions Code rid y license is in full f e d eff ❑ ❑ ❑
z 0 i - License lass__ Lir.Numbs
4 m r w Dale Contractor
a Y BUILDING PERMIT
¢ o a OWNIi R-B UILUBR DECLARATION INFORMATION
w ; LL H I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
u O j Law for the following r,asom(S,c,7031.5,Businessand Professions 4 VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which structure Permit to construct, tl,q
¢ W ¢ p improve,demolish,or repair any structure,Prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL
Is w m e- he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Hzi
Law(Chapter 9(conennencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r m llm basis for the alleged exemption.Any violation of Section 7031.5 I
I 9TOAHES I TYPE COITSTR.
by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001.).
O I,as owner of the property,or illy employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does.such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such improve-
mentsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the Owner-
builder will have the burden of proving that he did not build or in,- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE5 IND a Pe Omer
D I,as owner of the property,am exclusively contracting with ❑ 11 1:1licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 gG$ES$ORS A CEL N0.
and Professions Code:The Contractor's License Law does riot 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 contmctorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I an,exempt under Sec. ,B.&P.C.for ods WATER HEATER W/VENT.- 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00 -'
I hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensalipp Insurance,or a certified ZONING ENG.SITE NO.
copy thercof t5 3g0p,�5�.(:.I.
Policy NoIJ rQA0Wpany L J ti
O rtil red copy is hereby lmuen•J.
Z Z di, py is filed wit 'e,pection division. FIRE SPR INK ENERGY T-24
F- O Appbcant MISC.- REFER TO ORD. Y � N❑ V ❑ NE]
Cr �' C.Rl IE CA1'6 OF 1' RMRIION FRO ORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG. Y N V NF
EL Z( This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less
-) O 1 certity that in the performance of lire work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensalion Laws of California.
Date Applicam ALTER OR ADD TO MECH. 5.00 BUILDING
} tan NO'flCli 'I'O APPLICANT: If,oiler making this Certificate ifcutc of P's-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wish FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.N0 4.00
CONSI'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and stale that too above V ENTI LATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
40 ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autlwrior representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)BEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. '
fWc) 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 consequence of the
Hiro,.,lhisper it, MECH.CONT, LIC.NO. MECH.
�- TOTAL TOTAL
a ore icant/Co tactor Dat
INSPECTOR COPY