09714 APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aooH6hss lu // � �ff / BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09714
OWNERSr� PLAN CHECK VALIDATION
.'j!}ME QTY. ELECTRIC PERMIT FEE
• 1 1 QHONE
CONN TRACTOR'S (`JJ11
MEUTLETS-SWITCHES-RECEP 10.00/1.00
1( Luc.Nd LIGHTING FIXTURES 10.00/1.00
ADDRESS DDREPPLIANCES-RESIDENTIAL 4.00
1
^CONTRA1 PANELS 10.00 DATE OF APPLICATION
ORRCNITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE D.C.N0.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^
ASMOTORS SEE FEE SCH. �f'P+�•+
ADDREDDRESSS
SERVICE CHANGE 20.00
o o LICENSED CON'fRACPORS DECLARATION TEMP.POLE 30.00
a v u I hereby affirm that 1 am licensed under provision of Chapter 9 ISSUANCE DATE
m G m (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions de,a,, my license is in f all f, an�eft'c ❑ ❑ ❑
z o w - License Clas I.Ie.Num her E! 17)�
o H w Late 12/ LZ_a• Conlraclo
a y f /67 r BUILDING PERMIT
¢ ¢o a OWNER-BUILDER DIiCLA RATION' INFORMATION
w g n y I hereby affirm that 1 am exempt from the Cmttrudor's License MISC.- REFER TO ORD
FUO J Law for the folluwingreasun.(Sec.7031.5,Businessandl'rofessums PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requiresa permit locnnstrucl,alter,
Q'2 ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. .ELEC.
a wDLL requires the applicant for such Permit to file a.signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
z ¢ Law(Chapter 9(cummencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE It/tF
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a by any applicant for a perm it subjects The applicant loo civil penally
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
O meats are not hrough
ownemployees.for sale.
11,ed that however,
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
meals are not in Mnded or offered far sale.11.however,the building
or Improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
RES INC CON PB Other
Prove for Purpose ol'sale.). INDUSTRIAL WASTE INTER. 30.00
❑ L as Owner of the property,he 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 antr owner of property who builds t r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such cense projects with a cnntracWrlsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Conhactuis License Law.iY TRACT NO. PARCEL NO.
❑ Tann exempt under Sec. ,B.&P.C.for dtis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK BRS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy The,eu (Sec 3800,Lub. �/�7��
1'olfy N�COmpany'�-�j�'tCLI
Corlfied Cop is hechyfurnsled. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy Ia filed with Inc city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
PERMIT ISSUANCE 10.00
Lu - CIiRTIIIGOMPOF EXEMPTION FROMWORKIiRS• FLOOD ZONE A.L.U.C.
CL COMPEENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
� (This section Scud not be eompleteA if the punnit is for one TOTAL
hundred do that it, the pe lesr)
} LL _O 1 certify that f the performance Of thenwork fur which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
` 0U mit is issued,1 shall not employ any parson in any Ina Cali so as l0
O w become subject to the Workers'Compunsat ion Laws of Culifimvia.
a Date ApphcaCt ALTER OR ADD TO MECH. 5.00 BUILDING
} Do NO'T'ICE '1'0 APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should beconm subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
C'ONSTRUCI']ON 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.). H EATING UN IT(TO 100,000 B.T.U.) 8.00 5F O
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address d ELECTRIC
I certify that I have read This applicationand state That the above VENTILATION FAN (SINGLE) 4.00
. information is correct. I agree to comply with all city and county PLUMBING
ordinances mul %atc laws relating To building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby'authorixe representatives Of this city to enter upon the BOILER-COMP (Over 100,000 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,a inst liabilities,judgments, costs and expanses which (/L CONST.TAX
may ig/an way accrue ins(vid City in consequence of the PERMIT ISSUANCE 10.00 U
grant 6 his permit. MECH.CONT. LIC.NO. MECH.
TOTAL .2.3 al, TOTAL
gra ur,-f fi ontnctor at
INSPECTOR COPY