09702 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 09702
ADORES
PG BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME ply OTY. ELECTRIC PERMIT FEE
• G,1.6& V I/GCrJC DNE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
IC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS
R 's APPLIANCES-RESIDENTIAL 4.00
A
PHONE•Z- 'J7 PANELS 10.00 DATE OF APPLICATION
ono"ITE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
ENGINEER
LID.No. SIGNS TRANS. 3.00
moo ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDDRESSDRESS
APPLICANT MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 �J
woo LICENSED CONTRACT ORS DECLARATION TEMP.POLE 30.00ar /• ��/��
<ar So 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
So luunmencing with Section 7000)of Divion 3 of the Business and
�n ¢ BLDG. ELECT. PLG. M�.
H h i Professions C with
S y license is in full fore,
Z 0 m- License CIas - r[�_Lie Member(4 y.
a w F 2 Date Contractor
a x orI11 El
BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
0 o UINFORMATION
X 3 LL H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
I� oas Law for the following reason.(Sec.7031.5.Businessand Professions pERMIT ISSUANCE 10.00 VALUATION
Code:Any city or county which requires a permit to construct,alter,
¢ m improve,demolish,or repair an structure.prior to its issuance,also ELEC.CONTR. LIC.NO.
6 ¢ pP' Y ELEC.
c¢ requires the applicant for such perinit to file a signed statement that TOTAL PERMIT TO
K
m Int is licensed pursuant to the provisions of the Contractor's License
z ¢
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
F i 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �[
M F o the basis for the alleged exemption.Any violation of Section 7031.5 .STORIES TYPE CONSTR.
dam _ by any applicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars fS5001J:
❑ 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 Law does not 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 TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered forpale.It.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one yeavof'completion, the owner- GAS EASYSTEM OVER 4(EA ) 200
builder will have the burden of proving that Ile did not b - . - . .
uild or im- BUILDING USE
Prove for purpose of Sale). RES IIID CON PB Omer
❑ I,as owner of the property,um exclusively contracting with INDUSTRIAL . t ❑ ❑ ❑ ❑ ❑
licensed contractors to construe tha project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 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 a contructorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
O I am exempt under See.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
\ W'ORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy tlmu.-of fSe<. Co pang ).J_,�
Policy icr -Company gClflfl!3LiG '
❑ Cctlified copy ix harahy furni,Amd.
FIRE SPRINK ENERGY T-24
Z p AppliuCertlfi opy is filed w'pR he city inspection division. MISC.- REFER TO ORD. v N Y N
~ rn a PERMIT ISSUANCE 10.00 ❑ ❑ ❑ ❑
LU - CIiR 'ICA OPSATI NIONPRUS RKERS' FLOOD ZONE A.L.u.C.
W >_ COMPIiNSATION INSURA CE PLG,CONTR. LIC.NO. PLG.
CL O ('this section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
::) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of lire work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so as to
Ow become subject tothe Workers'Compensation Laws of California.
y Dat° Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Es-
f" ? amption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN,CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
lire performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
I certify that I have read this application and state that the aboveVENTILATION 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 authorize representativesofthis city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL / Ov
above-mentioned property forinsp of this
purposes.to.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO -
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 db CONST.TAX
may in any way accrue against Said City in consequence of the , /J
grant' a of thiso pperm' . MECH.CONT. LIC.NO. MECH.
/ i TOTAL /i•� TOTAL
Si r pl cant on racto ate U
INSPECTOR COPY