09703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS � f 7
DA
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL V;1
03
OWNER'S PLAN CHECK VALIDATION
ME V. ELECTRIC PERMIT FEE
• v6 {�I/1�13ue�a N /J-7
CONTRACTOR r lr
�( NAME 3w ,1- UTLETS-SWITCHES-RECEP 10.00/1.00
A LL l; L-IG Uc.No. A LIGHTING FIXTURES 10.00/1.00 fly
ADDRESS DR' pp LIANCES-RESIDENTIAL 4.00 V
T ADDRESS
�j� OaQ NE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.0Q PERMIT VALIDATION
ZIPEM, METER OR POLE INS. 20.00
APPLICANTSd MOT
ADDRESS RS f,QgG SEE FEE SCH: CZ
SERVICE CHANGE 20.00
°a
0 o o LICENSED CON'I'RAC9'ORS DECLARATION TEMP.POLE 30.00
<u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
o, i (commencin with Section 7000)of Division 3 ol'the Business and
a g BLDG. ELECT. PLG. MECH.
F m i Professions Cade,anti my license is in full to d e ecL X" aI ❑ ❑ ❑
Z D a - License Classes 1 � Lic.Number
Dole y/ � Contractor
a
x a OWNER-BUILDER DECLARAU
' ON BUILDING PERMIT
¢o n u INFORMATION
E
g u-to I hereby affirm that I am exempt Irom the Contractor License MISC.- REFER TO ORD
a. 0 < Law forthe following reason,(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 W VALUATION $/FT.
� - 0 Code:Any city or county which requires a permit to construct,alter,
¢ ¢ a0 improve.demolish,or repair any structure.prior to its issuance.also ELEC.CON`R, f LIG NO. ELEC.
- LL
requires the applicant for such permit to IIIe a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License ELc�
z i Law(Chapter 9(commencing with Section 7000)o'Division 3 of the /
- a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
E x o
¢ r o the any
the aura exenpnibje tAny sthea applicant
to action7031.5 STORIES TYPE CONSTR.
n m by any inure
applicant for a pu hundred
Subjects the 0).): ant tov civil pomlty
of not more than Ove hmulmJ dollars(S5001.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,ax owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement Is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or ire- - . - . .
BUILDING USE
Prove for purpose cf,dr.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PS Omar
O I,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR$PARCEL NO.
and Professions Code.9'he C.r Ta rtor i License Law docs not apply
To
an owner of property who builds or improves tlmrcoo,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u contractor(s)licensed pursuant to SEWER-SAN EA.200ft/10.00
the Contract.,',License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.fur Ibis WATER HEATER W/VENT 6.00
Eason
owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, .5.00
I.hereby affirm that I have a certificate of consent to sell-insure,
71,a certificate of Workers'Compensation Insurance,or a cerlil'ied ZONING ENG.SITE NO.
'copy No, ffScc. CUUq00, b.C.&ALTIC,Q� 7 Ni -
Policy No, Company(j�3dd
<U _❑ eCe plied copy is herelb`y l�uumishcdjVLBJ FIRE SPRINK ENERGY T-24
c p n lir nt� .� ith tllc v inspct�on division. MISC.- REFER TO ORD. YE] NEI v � NE]
' CC CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
W > - COMPENSATION INSURANCE; PLG.CONTE. LIC.NO. PLG. V N v N�
CL Z 11 his section need not be completed if the permit is for one TOTAL
hundred dollarsfS 100) 0 less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 U becomt is e subject toued,I all net e lhe Work rspCorT pnsatl n Laws ofCa h.mixtu
pe
ED Uam Applicant - BUILDING
} W NOTICI7 TO APPLICANT: If,after.making this Certificate of nix- ALTER OR ADD TO MECH. 5.00
F Z cmplion,you should become subject to the Workers'Cumpenselm n 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)000QF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50 (�
Lender's Address ELECTRIC I C
vF I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned properly 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 CONST.TAX
may in any way accrue against aid.0 in consequence of the PERMIT ISSUANCE 10.00
tingof-this permit. �\ /-/'_ 1 ECH.CONT. LIG NO. MECH.
d/ TOTAL TOTAL
Applican(ICtiffluactor Date
INSPECTOR COPY ,