09711 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PROJECT lDENTI FIC
BUILDINTION PERMIT NUMBER
G PROAAPPLICATION & PERMIT
BDII.DING , r «,�y �ll crit 09711
ADOREss
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNIiRS PLANCHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
NU PHONE M 1I 'I
I.NRAcroAlRsOUTLETS-SWITCHES-RECEP 10.00/1.00
NEPC, Yl•
t' / /Cy L • U.,N .2 2 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S DOTRAOTOR'sADORE
PPLIANCES-RESIDENTIAL 4.00
/ (7em .T
PHO PANELS 10.00 DATE OF APPLICATION
ARCHfrEC PLAN CHECK FEE P.C.NO.
OR �'tl9rFk d G/�n.JDeiL PANELS (OVER 200 AMP) 20.00
ENCIry EE
LIC.NO. SIGNS TRANS. 3.00
AARCH,On
DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDDRESSDRESS
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w o O LICENSED CONT RACT'ORS DECLARATION TEMP.POLE 30.00
v U I hereby aff rm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r z "' (commencing with Section 7000)of Division 3 of the Business and
N Q >y BLDG. ELECT. PLG. MECH.
w 2 Professions C e,and y license is in full for an feet ❑ ,❑ ❑
z O m - License Class - Le.Number l7rl
9 = t w Dale Comnetor ' 7T-""
a x E H BUILDING PERMIT
¢ 064 OWN['R-BUILDER DECLARATION' INFORMATION
X 3 LL a I hereby at that I am exempt from the Contractor's License MISC.- REFER TO ORD
u0 ¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
r_ - Code:An or which requires Any city county y permit to construct.alter.
Qp Improve,demolish,or repair any structure,prior 10 its Issuance.also ELEC.CONTR. LIC.NO. ELEC.
ca Ie requires the applicant for such permit to file a signed statement thatTOTAL PERMIT TO
w Z a he is licensed pursuant to the provisions of the Cont License
H i Law lChun
p4r 91conuencing with Section 70001 of Division ision3D1''(he
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
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(SS00)J:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sulc compensation,will do the work,and the It
is nut
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does riot 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 TOTAL ACREAGE
e o
himself through his own employees.Provided that such on
meritsfm not intended oroffered for Sale.If.however,the building
GAS-EA.SVSTEM-1 INCA OUTLETS 6.00
or improvement is sold within one year of completion, - . - . .00 the owner- GAS EASYSTEM OVER 4(EA) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and PoWessiuns Code The Contractor's License Law does or 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 contractors)licensed pursuant to SEWER-SAN V-STORM EA.200ft 10.00
the Contractin's License Law. / TRACT NO. PARCEL NO.
❑ lain exempt under Sec.-,B.&P,C,for this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
' I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec_3 OO,Lab.C.I yam,,
Policy No Flampany�QtELIY""vtln "(
C Cctlil led copy is hereby furnished. FIRE SPRINK ENERGY T24
Z z C Cumllu Ey is,filled wi h theitY inspcdion divixion.
O Applicant ..,.. FAL 21,A=?he cty ro,e MISC.- REFER TO ORD. Y ❑ N❑ r ❑ N❑
CEk'fIPICEXEMPTION ROhWORKERS PERMIT ISSUANCE 10.00
FL000 ZONE A.L.U.C.
LL COMPENSATIN INSURANCE
PLG.CONTR. LIC.NO.CL PLG.
Z (This section need not he completed i1' the permit is for one 4 TOTAL v❑ N❑ V ❑ N❑
hundred dollars(S 100)or Icss.l
L) O 1 certily that in the perti mance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is .sued,1 shall not cmpluy any person in any manner so as to
U become subject to the Workers'Campensalion Laws of California.
a Dale ApplicantBUILDING
>_ W NOTICE'f0 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
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 sha11 he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 - SEISMIC FEE
I hereby affirm that (here 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certily that I have mud this application and style 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-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL 7
above-mentioned property for inspection Partin A"
(We) agme,To save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino upw accrue
tie;inaidrents, coysund expenses which PERMIT ISSUANCE 10.00 ✓D CONST.TAX
may in any w ocerue ag4m said City in consequence of the
granting dl'Q permit MECH.CONT. LIC.NO. MECH.
TOTAL�� TOTAL
Signa tic nt/ gmmclor U e
% INSPECTOR COPY