09556 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT'PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BDILDING / APPLICATION & PERMIT o^
55n
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ f PLAN CHECK VALIDATION
1E((11 CITY. ELECTRIC PERMIT FEE
.TS NO ES HONE
•'� N°"TRAcrons OUTLETS-SWITCHES-RECEP 10.00/1.00
-��j uc.No. LIGHTING FIXTURES 10.00/1.00
c RAcrGR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
C .ONE PANELS 10.00 DATE OF APPLICATION
ogcHlr T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
moo Ess ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
/ W '•"",�•/
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w w o LICENSED CONTRACTORS DECLARATION TEMP.POLE ( 30.00
a o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w z w (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
F. Professions Cod ,an y license is in full force and effect.
z O� License Class Lie.Number
° w Date o- +-at Contractor
Fw _ - -..--��
a x f 01
BUILDING PERMIT
¢ ¢ m a OWNER-BUILDER DECLARATION
A ° d 0 INFORMATION
w ; LL i_ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL D j Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
H _ g PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
° ¢ requires the applicant for such permit tD file a signed statement that V TOTAL
w m
he-is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fzi
Law(Chapter 9(commencing with Section 7000)of Division3ofthe �M/0. �0��'
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
s i °
¢ r o the basis for the alleged exemption.Any violation of Section 1031.5 STORIES TYPE CONSTR.
a 3 m by any applicant for a permit subjects the applicant to civil penalty /
of not marc than five hundred dollars($500y): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,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 Lew 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
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-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or inn- BUILDING USE
RES IND CON PB Other
prove fors owner of theJ. INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,he Project
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 nut apply
to an owner of property who builds tt improves IherL•on.:md who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for simh cense L with a contugod sl licensed pursuuns m
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&RC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF'NSA'I'[ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell=insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ccrsified
7 copy thereof(See.38Q0,Lah.C.l� /1 4_T/„2 n
Policy Na E)py i( fjj�� /'ll`I1C rCl
1 ❑ Ce Ci copy is }�rylT�l'unushcd. r
Z Z� ❑ C NI c py ( fiml with`Ihc 'ily inspcclion division. FIRE SPRINK ENERGY T2G
p npplica MISC- REFER TO ORD. S Y � NEJ Y ❑ IN
~ w PERMIT ISSUANCE 10.00
- ,RTII'IC 7ij li%5M1'TION PROM WORKERS' FLooD ZONE A.L U.C.
LU - OA 3NSATION INSURANCE PLG..CONTR. ❑C.N0. PLG. ❑ ❑ ❑ ❑
CL O (This section need not be eon,plerod if the permit is for-enc` TOTAL - V N V N
Z hundred dollars(Sl00)or less.)
U O 1 certify that in the performance of,the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any.person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
Go NOTICI7 TO APPLICANT: If,after making this Certificate of six.
Z emption,you should become subject to the Workers'Compensation
1= APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
su
U ch provisions or this penny shall he demned revoked. AIR HANDLING UNIT(TO 10,0000 F.M.) 4.00
CONSTRUCTION LENDING-AGENCY AIR HANDLING UNIT(OVER 1OPMC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lendingagency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of(tic 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 HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
1 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-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree 1. save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liatill ties,judgments, costs and expenses which CONST.TAX
may 'n any way ac/cru against said City in consequence of she PERMIT ISSUANCE 10.00
'ant g of this permitMECH.CONT. LIC.NO. MECH.
\ / TOTAL TOTAL
icanyyontractor Date
INSPECTOR COPY '