9405 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT.I DENTIN CATION .PERMIT NUMBER
9DILDING -y-- L✓� APPLICATION & PERMIT
ADR.Ess .��o , .rT�✓fin f BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 9405
( .�J_ OW 'S - - PLAN CHECK VALIDATION'
NAME i / rQTY. ELECTRIC PERMIT FEE
b , , `k7M
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
rt
/ LIC.- LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
c PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
OR .
ENGINEE
LIC.No. SIGNS TRANS. 3.00
RCW
ADDRESS ErvG. ♦ SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
r )
nP - EMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS , SEE FEE SCH.
SERVICE CHANGE 20.00
o o LICENSI iD CONTRACTORS DECLARATION TEMP.POLE 30.00
Q ow w I hereby affirm (hat 1 am licensed underpnrvisionsof Clmpter9 - ISSUANCE DATE
m Q m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z Professions Code and m Iicense is in full for d.•fjecly7�
z
0 . ^-^// License(Jess J.�,..�.h�y�Lie Number*AD,!1-(_(,� ❑ ❑ 1:1
❑
9 r. Dames I S{.L$.�Contractor O_-
a m E '/ - � `^� ��� A'-' ' - h BUILDING PERMIT
¢ 0 Li OWNER-BUILDER DECLARATION INFORMATION
wg u U 1 hereby turner that 1 a...exempt from-tire Contractor's License MISC.- - REFER TO ORD
LL o e Law for the following reason.(Sec.7031.5,Businessand Profc,mi s VALUATION $/FT.
u, PERMITIISSUANCE 10.00 vy
Codr:Any city or county which structure permit to conrimcl,alter, _
¢ ¢ ¢ improve,demolish,or repair any structure,prior to its issuance also ELEC.CONTR. u LIC.NO. ELEG yy��
¢ requires the applicant for such permit to file a signed statement that TOTAL jyV
a w he is licensed pursuant to lire provisions of the Contractor's License PERMIT TO
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
_. •,� i D
Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n312 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five handed dollars(S500)J:
❑ 1,as ownenof the property,or on,, employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the stmctum 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 thercon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA S TOTALACREAGE
himself or through his own employees,provided that such improver
mints are not intended or offered for sale ll',however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, . . .00 the owner- GAS-EASYSTEM-OVER 4 (EA ) 2
builder will have ere burden of proving that he did not build or hie BUILDING USE
prove forpurpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CON PS Other
❑ . .
I,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 thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u contractors)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt Coder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE Ace FILE NO.
WORKHRS'COMPBNSATION DECLARATION WATER TREATING EQUIP. 5.00
Thereby affirm that
WI havero •rtiRcm'of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Worker oo lulu, ora err'tied
copy thereof'Ser..3800
Policy Not, iJd co
❑ Cert�iricd`cOvjf shhtr famish FIRE SPR(NK ENERGY T24
Z Z -.❑ Certified coy is IT with I city in e n division.
O-{' Apo] t MISC.- REFER TO ORD. Y ❑ N Y ❑ NE]
N/ CERT6FCAT '13 XGh1 TIO OM WORKERS' PERMIT ISSUANCE 10.00 FLooD ZONE A.L.u.C.
LI > PENSATIO SURANCE PLG.CONTR. LIC.NO. PLG.CL O (This rectited nor be completed if the permit is for one TOTAL V N� v N❑
Z) Z hu nd 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
LL U mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of California. '
a Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOT I CIi TO APPLICANT: If,.after making this Certificate of E.-
F- cmpton,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nest forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE r
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tic performance of the work for which this permit is issued(Sec. MICROFILM
3097.Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address _
I-certify that have read this application and state t hat the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to Comply with all city and county g01 LER-C )MP(3 H.P,o-100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and _
hereby authorise
rep of this city to eo(ur upon the 201 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned > ty for ins •• n rposc
(We) ae ra y and k p mlcsr the City of MISC.- REFER TO ORD. N
Cupertino a illties dgmunrs, o and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in a a C ainst said i n consequence of the
Stanti1, Cohrs mil. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Si, aid, Applic t/C coon Date
J INSPECTOR COPY
I