9501 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
10 J
•1 �' /v � O ,BUILDING - ELECTRICAL-PLUMBING-MECHANICAL J
PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PHONE -
CONTRACTOR'S '• /
NAME J.// /� /IC �O f�y 38� OUTLETS-SWITCHES-RECEP 10.00/1.0070
LIGHTING FIXTURES 10.00/1.00
corvrRAcrons yQC6
APPLIANCES 4.00 J�
A ORES,, S
eZ / ` HOLNE2)2yjY 3 PANELS 10.00 DATE OF APPLICATION
oogcurecr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRREOR SS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
2,P EMP.METER OR POLE INS. 20.00
ADDRessrs p MOTORSi SEE FEE SCH.
L SERVICE CHANGE 20.00
pp L i
w a o LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
< Z u I hereby affirm that 1 am licensed Linder provisions of Chapter 9 ISSUANCE DATE
m a (commencing with Section 7000)of Division 3 of the Business 1 BLOC. ELECT. PLG. MECH.
H ti z Professions Code,and my license is in full force al de
elle-t s
0 o w - License Class Lie.Numbe�`l, o ❑ ❑ ❑
9 r- w Date a /_t__��Contractor
a m SE rj /p / BUILDING PERMIT
a OWNER-B UILDIiR UECLA RA'f10N
0 u v INFORMATION
in3 1 hereby alfirm that I am exempt from the Convectors License REFER TO ORD
MISC.-
u 0 i Law for the following reason.(Sea 7031.5.Business and Professions VALUATION $/FT.
PERMIT ISSUANCE 10.00 '1
Code:
e,demysh countywhichany requires apermit toconsuance,also O
Q Q¢ improve,demolish.Or repels any structure,prior 10its 1s5Ui1nCl',aI50 ELEC.CONTR. LIC.NO. ELEC. p¢
n w0 IE requires the applicant for such permit to file a signed statement that TOTAL d� If PERMIT TO
m he is licensed pursuant to the provisions of the Contractors License _
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
T CI the basis for the alleged exemption.An
2rge p Any violation ofScdion 703L5 STORIES TYPE CONSTR.
d 3 ,. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
.r ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole com pensalion,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 TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building... GAS-EA.SYSTEM-11 INC.4 OUTLETS 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 im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB GOP,
❑ 1,as owner of the property',and 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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclons)licensed pursuant to
the Contrarmc's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for thi> WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACO,OATE ACC.FILE NO.
WORK ERS'COM PENSAI ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to sell-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensat i0 InsuraSnce,or a certified
copy thus f e 38 ,Lab.0 ,�z/10NT
Policy No. 1 ny
r� �)
0 O Certified op s co, y un151 d 'N 2P'71 FIRE SPRINK ENERGY T24
Z Z ❑ Certified y 5ti.filed 'th lh mty inspfction division. MISC- REFER TO ORD.
Applicant y E] ryC3 y 11 NEI
X y ,CER '1 ATE OP F- ':M 10. 'ROM ORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d ❑ ❑ [3 ❑
0 (This section need not be completed if the permit is for one TOTAL v N y N
::I Z hundred dollms 1510()or less)
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so a5 to
U w become subject to the Workers'Compensation Laws of California.
ED Date APDlicanl ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Cerlificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith conplly with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work lot which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Add«ss ELECTRIC Q
Icertifythat[have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale 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 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection PUrPOSLS.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino gains( liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i a way accrue minst said-@'1 nscqucnw of the
gunk f this permit MECH.CONT. LIC.NO. MECH.
V TOTAL TOTAL
Si a ofAppli� or/ ntracW Ualc
INSPECTOR COPY