9433 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION,, PERMIT NUMBER
BU LOINIS
ADNG APPLICATION & PERMIT ����
S
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Ow ER's PLAN CHECK VALIDATION
NAME
• (1 CcJ E,Q,0.�0"//A - OTY. ELECTRIC PERMIT FEE
PHONE
MNTW
S-
ME s UTLETS-SWITCHES-RECEP 10.00/1.00
RLAC
1 / ND, LIGHTING FIXTURES 10,00/1.00
COGRESS oR's PPLIANCES-RESIDENTIAL 4.00
CONTRAS
PHONE _ PANELS 10.00 DATE OF APPLICATION
OR RCHITE T PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AOGRREOR SS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLI EMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o 0 o LICENSED CON"T'RAC'TORS DECLARATION TEMP. POLE 30.00
rc u u I heathy ufflnn that I am licensed under provisions of Chapter 9 _ '1.� j ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and Y/ ; BLDG. ELECT. PLG. MECH.
FD i Professions Code,and my license is in full force a�Id effect ❑ ❑ ❑
z 0 m - License Class Lis.Number 1 J Sts Q 4 /_ R LE
9 m °w Date 9 �- _ g Contractor p1 L A(R PI
¢ m s may, BUILDING PERMIT
iL R w a OWNER-BUILDER UECLA RA'T'ION " -
iL i.a _ I hereby ffinn that I am exam t from the Contractor's License MIS (/ % 1+C REFER•TO ORD INFORMATION
3 u y Y a P VALUATION
FLLOj Law for the following reason.(Sec.703L5,Businessand Professions PERMIT ISSUANCE 1 10.00
Code:Any city or county which requires permit toconstruM ul«o
T ca Q improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.No. ✓ ELEC.
- O ¢ requires the applicant for such permit to Idea signed statement that TOTAL PERMIT TO
u w m lie is licensed pu¢oam to the provisions of the Contractor's License
Uzi Law(Chapter 9(cornmencing with Suction 7000)of Division 3 of lire
¢ Business and Professions Codd or that lie is exempt therefrom and OTY. PLUMBING PERMIT FEE 6.
T H p the basis for the alleged exemption.Any'viohn ion ol'Section 7031.5 STORIES TYPE CONSTR.
Ate - by any applicant for a Permit subjects the applicant toe civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not mom than five hundred dollars(S500)J:
❑ [,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 400
their sole compensation,will do the work,and the structure is not . .
OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'hc Contractor's I.Iccnm Law docs not apply to an owncrof'
property who builds Or improves thereon,and A!)does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• .cus are through into de ownemred fors' le Ii,however.ed that th impnrve GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA) 200
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE it
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the Property,am exclusively contracting wits ❑ ❑ ❑ ❑ ,,❑
licensed contractors to construct the project (Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:Thu Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractoRs)licensed immuctot to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200/t/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAKC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.PILE No,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate sire onscut to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy lhereofiSec.3800,Lab.C.). '
Policy N . I any
Q ❑ Cer I led copy Is c cby l'um ished. FIRE SPRINK ENERGY T2
Z Z ,�I Certified copy is tiled with tire city inspection division.
O A0phcam MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
jr w CERTIFICATE 01;EXEMPTION FROM WORKERS' PERMIT'ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LLQ COAIPINSATION INSURANCE PLG.CONTR, LIC.No. PLG. v❑ N❑ Y ❑ N❑'
CL Z( This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.) +
U O 1 certify that in the performance of the work for which this per- pTV. I, MECHANICAL PERMIT FEE FEE SUMMARY
LL H m
Hill is issued,I shall not employ any person in any manner so as to
O becomesuhjeCl to the Workers'Compensation Laws of California.
0 Do Date Applicam ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE '1`0 APPLICANT: If,after making this Certificate of lia-
F ? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Rlrthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 d,
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that in... is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Car
Lender's Name
Lender's Address _ HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I ...ifyflatlhovercad this application and mawamr the above VENTILATION FAN ISINGLE) 4.00
qy information is mrrcci. I agree to comply with all city and county -COMP(3 H.P.or 100,000 B.T.U) 6.00 PLUMBING
ordinances and state laws relating to building construction, and BOILER
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100000 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 consequence of the c7
granting ol'lhis porn i[. MECH.CONT. LIG NO. MECH.
./_Y/!I'.A .1 F � I / ' TOTAL ^ Q ^ TOTAL
Iign�ol p Iicant/ nt Dat C 1 r
INSPECTOR COPY
I