9482 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRESS DING APPLICATION & PERMIT ����
ADORE55
IL ING -ELECTRICAL-PLUMBING-MECHANICAL
OWNS '5 PLAN CHECK VALIDATION
�/L rvAME 1x QTY. ELECTRIC PERMIT FEE
l
NAMERACTOR's r UTLETS-SWITCHES-RECEP 10.00/1.00 t
•86YV1M aIC,NO. 75 D LIGHTING FIXTURES 10.00/1.00
TCONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS J/
'a "r•SrvE �� •sQ PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) ZO.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rTEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. /J
�// /I /�
R�O 1 CIL , SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q U 1 hereby affirm that I am licensed under provisions of Ch.plc,9 ISSUANCE DATE
as n IConunaneing with Section 7000)of-Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
H m i Professions Code and my license is in full fort"nd efl'eSt ❑
z O License Class = Lic.Numberyi7 4 'f✓i7
o h r w )me Contractor
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a o dU INFORMATION
X g u y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O j Luw for the following reason.(Sec.7031.5.Business and Professions VALUATION S/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
re ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
p I-y M requires the applicant for such permit to IIIe a signed Statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License / L
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
2,t-Oo the basis for tire alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant noacivil penalty q R-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).): _
Cl 1,as owner of the property,or my employees with wages as B ROTECT. 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,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon,andwho docs such work FIXTURES-PER TRAP 5.00 50.FT.FLODP APER TOTAL ACREAGE
himself or through his own employees,provided Ilwt such improve-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one yeor of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA., 2.00
builder will have the burden of proving that he did not build or or- BUILDING USE
prove for purpose of mleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CDN PB .Omer
❑ I,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 docs not apply '
to an owner of property who bolds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
Contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 _
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tarn exempt under Sec. .B.&I'.C.for this WATER HEATER W/VENT fi.00
realUn I
- Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WATER TREATING EQUIP. 5.00
W'ORKIi RS'COhIPIiNSATION DECLARATION `
I hereby affirm that I have a certificate of consent to m1f insure, ZONING ENG.SITE N0.
1. or a certificate of Workers'Compensation Insurance,Or a certified
copy thereof(Sec.3800,Lab.C.)..� /` '
I'n0 Nn7.1�eO ,r, Y-1ll.C[�I_Ll./](1J7
Z ❑ Ccrtiti, cop ylereby fu isht - FIRE$PRINK ENERGY T44
Z Z �y C'itif'ied-'opy is Filed with'ti C�'ity inslfeclion division. _
O npDll;cI-('/7y�(��_ MISC.- REFER TO ORD. v❑ N❑ �.;v ❑: N❑
CC T CER 1'(j.-1 C,1TE OF Ii x EMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE�w. A.LU.C.
W > COMPENSATION INSURANCE PLG CONTR. LIC NO. PLG. �`
O 1'I'his section need not be completed if the permit is for oneNs
TOTAL p� ' Y❑ N❑ f Y❑ IN
Z hundred dollar,(S 100)or less.)
L) O I certify that in tine performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any roomer so as to
O w become subject to the Workers Compensation Laws of California.
Dat`' Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
a
} vt NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex-
F-. ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most 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 10=11F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a Construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
tire 3091 ,v.C.)nce of the work for which this permit is issued ISec HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
'Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the uhove VENTILATION FAN (SINGLE) 4.00 +
• ofmioation is correct.1 agree to comply will,all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING Q
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over loo,000BTUISEE FEESCH. 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
ma in any way accrue ag st said City in consequence of the
grant g o-this peranit. MECH.CONT. LIC,NO. MECH.
TOTAL TOTAL
Igpe ore of App Icent)Contractor a e
INSPECTOR COPY