8509 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aDORE55
CidQrAeR
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNERS'' 8509
PLAN CHECK VALIDATION
nAME QTY. ELECTRIC PERMIT FEE
BAS OF RT HG E
NAMERACTORs UTLETS-SWITCHES-RECEP 10.00/1.00 Yl
LIC.N(R LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S Wilyens Crk BI V APPLIANCES-RESIDENTIAL 4.00
Fat. �u irt7W0 (HONE 252-207PANELS - 10.00
DATE OF APPLICATION
ARCHITECT
OR (OVER 200 AMP) 20.00 A PLAN CHECK FEE P.C,N0.
OR
to EEO
L .NO. C009175 SIGNSTRANS. 3.00
ARCH.OR Esm. PERUZWkIJUTION
ADDRESS SPECIAL CIRCUIT 5.00
18008 Skypark Cr. N20
zIP EMP.METER OR POLE INS. 20.00 A 11n 9
aooliess MOTORS SEE FEE SCH. NU17 ^P O 19
C2C. Z �� rl �ll�en�ACr0141 SERVICE CHANGE 20.00 CltYOf 85
a o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��PBrt100
Q U u I hereby infirm irm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
in (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT., PLG. MECH.
w i Professions Code,and my license is in full force and effect.
z o m- License Cla s Lie,N'mnber ❑ Il
Q y H w Dute�Convacmr,h IQRE-�
¢ M s 1 FI BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
" MISC.- REFER TO ORD INFORMATION
wLL I hereby affirm Thal I ten exempt I'Rml the Contractor's License VALUATION $/FT.
LL o.¢ Law for the following rcasom fSee.7031.5,Nusinessand Professions PERMIT ISSUANCE 10.00
� - Code:Any city or county which requinesa permit to construct,alh`q
rtw r J ELEC.CONTR. LIC.NO.
2 ¢ p improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.
- O u requires the applicant for such permit to file a signed statement that TOTAL /-P IT TO
u w$ he is licensed pursuant to the provisions of the Contractor's License / /
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe L'/
¢ Business and Professions Code)or that he is exempt therefrom mW QTY. PLUMBING PERMIT FEE
¢ H p the basis for the alleged exemption.Any violation of Section 7031.5STORIES TYPE CON TR.
n ; W by any applicant fora permit subjects the ulmlicanuoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
o1'not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 OCC. Roue E5.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,GOND. 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 50,FT.FLOOR AREA T AL ACREAGE
• himself or through his own employees,provided that such inllrove. -11NC.40UTLETS 6.00
tents are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM
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 nil build or airGAS
IND CON PB Omer
proos
ve for purpose oI sale.f INDUSTRIAL WASTE INTER. 30.00 El El❑ I,as owner of tire 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 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 project,with a COnlractmos)licensed Persian(t0 SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
•C .D ACC.FILE N0.
WORK I:RS'COMPF.N'SA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.38�010p,p�Lab @C.).
Policy NO._}•S.]_(1.C71p01p14
O s{ Ccrt:led d(pp 14914 Y r `d RE,PRINK ENERGY T-29
Z Z 41 Certifie opy is fled ith the city inspection division.
FO Applicant$ ' 0�'-��TzR�a�rt� 1i- MISC.- REFER TO ORD. Y � N[_ Y � N�
� N Or RTI 17ICA'TF O F-F-XEM PI TO N F ROM WO R K F-RS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.u.O.
LU > COhIPI uSAT10N INSURANCE PLC.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N� Y N�
D Z load red dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ H mil is issued,I shall not employ any person in any manner so as to <
O w Dlvcppl
become subject to the Workers'Compensation Laws of California. BUILDING d
C. Aicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT, If,after nm king this Certllicate of[is-
Z eruption,you should become subject to lire Workeri Compensation 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=C.F.NL) 4.00
CONSTRUCTION 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 perfor97, mance of tire MICROFILM
e work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Name x ELECTRIC
I certify that I 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
ILER-COMPI3 H.P.or 100,0008.T.U) 6.00
ordinances and state laws relating to building construction, and BO
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
(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
I may is any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIG.NO. TH.AL TOTAL
hg at pp scant/Contractor Date
I
INSPECTOR COPY