09718 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0971 $
ADDR%ESS co
S - S"1 S I• . 11��� .1- v BUILDING-ELECTRICAL-PLUMBING-MECHANfCAL
OWNER'S teff W !"/ / PLAN CHECK VALIDATION
a ME QTY. ELECTRIC PERMIT FEE
• 6 �
`..NE U N'
TRACTORS VUTLETS-SWITCHES-RECEP 10.00/1.00
1P( MEd
Ft 1 LIC.NOW Z LIGHTING FIXTURES 10.00/1.00 y
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 4
rsIs /1�r �1F
` lJ„ S' J -PROb - PANELS IO.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ADDRESS FNc' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
zip rrEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
"' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Dz Professions e m I Iy license is in full fort n 1 Ut t�
License Clam_Lic.Numbs ❑ ❑
o m H .,ate } ConlmctdJJ�
y E w / " K 7� BUILDING PERMIT
M a w s OWNF;R-BUILDER DECLARATI N
LI MISC.- REFER TO ORD INFORMATION
'xu 3 a- H I hereby affirm Our I am exempt from the Contractor's License VALUATION $/FT.
Hwoj Law for the following reason.(Sec.7031,5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any cityor county which requires a permit to construct,alter.
2¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ca
D M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m a- he is licensed pursuant to the provisions of the Contractor's License _
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
< Business and Professions Codc)or that he is exempt Ihcrcl Run and QTY. PLUMBING PERMIT FEE
X F o Ole basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
a ;a by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($5000.):
❑ 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 I,not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly 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(hat such improve-
Incurs are not intended or offered for sale.If,however,the building, GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
r 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 im- BUILDING USE
prove RES IND CON P
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 B ower
ID 1,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 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Ihcrcon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BA P.C.for this WATER HEATER W/VENT 6.00 �.v.
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI,RS'COMPHNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconscnl to scl oinsun,. ZONING
or a certificate of Workers'Compensation Insurance.or a certified ENG.SITE N0.
copy there ( c 80Q'Pum. j G
I'D is N� Company
O Cc,Bled copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ NO'
CC CFRTI171CAT'E OP EXEMPTION FROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. .
CL (This section need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ N❑
Z hundred d.IIhl,$100)orlcsx)
U O 1 certify that in the perbinimuce of the work fin which this per- OTY MECHANICAL PERMIT ,FEE FEE SUMMARY
LL F- mit is issued,1 Quill not employ any person in nny manner so us to
O W become subject to the Workers'Compensation Laws of California. BUILDING
y Dine Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: IL after making this Certificate 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 comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO)000OF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance o1the work for which this pennit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 4
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application andslat,that the above VENTI LATION FAN (SING LE) 4.00 (�
• information is correct. I agree to comply wit 11 all city and rommty PLUMBING.
ordinances and state laws relating to building Construction, and BOILER-COM P(3 H.P.or100,000B.T.U.) 6.00 \
hereby authorize representatives of this city m cutin upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL pl
above mentioned property for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
, Cupertino// )hst liabilities,judgments, costs and expense,which PERMIT ISSUANCE 10.00 f/1/ CONST.TAX
t y drlY Jls'aY accrue against said City in consequence of the
gr:mC g O his perrm MECH.CONT, LIC.NO. MECH.
/ -1/ -. TOTAL a ch TOTAL '
iynamfe, f p t/Contractor Date
INSPECTOR COPY