09688 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BLOING APPLICATION & PERMIT
AoDIoREss 09688
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNS 'S GAG. PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
•
NONE
NAMERACTaas 71 OUTLETS-SWITCHES-RECEP 10.00/1.00 Z
S (� Llc rvo 71LIGHTING FIXTURES 10.00/1.00 ✓`
CONTR CTORs APPLIANCES-RESIDENTIAL, 4-00
ADDRESS C
�.e PRON 7 PANELS 10.00 DATE OF APPLICATION
ARCHITECT K PLAN CHECK FEE P.C.NO.
OR SAN ASIl3 PANELS (OVER 200 AMP) 20.00 p
ENGINEER
LIC.No. SIGNS TRANS. 3.00
moo Ess ENG' SPECIAL CIRCUIT 5.20 PERMIT VALIDATION
ZIP EMP. METIER OR POLE INS. 20.00 0 `
APPLICANTS
MOTORS SEE FEE SCH. �{-OL1•d'+''J
ADDRESS
SERVICE CHANGE 20.00 pp-1
w02 LICENSED CON FRAC DECLARATION TEMP.POLE 30.00
Q Z u I hemhy ah urn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business and
�n< BLDG. ELECT. PLG. MECH-
r i 1'mfesslons CyA0.tyle my license is in full( e eQ c
z 0 m License Classt�-rd Con ract., ❑ ❑ - ❑
9 w F DatcContrador
9-F 9T to
M m or a OWNER-BUILDER DECLARATION x BUILD NG PERMIT
E ¢o a 0 INFORMATION
K
I hereby affirm than I am exempt from the Contractor's License MISC.- REFER TO ORD
LL
04 Law for the following lemon.(See 7031.5.Business and Professions (] 1 VALUATION $/FT.
❑ - Code:Anyckyorcounty which requires a permit to construct,alter, PERMIT ISSUANCE 10.00
0 improve,Demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG
a w a a m requires the applicant for such permit to file a signed statement that TOTAL 9 ✓�/ PERMIT TO
he is licensed pursuant the provisions of the Contractor's License
FZs-
Law(Chapte r 9(cum me neing wit h Sect ion 7000)a f Division 3 of the EL�G7
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I- mthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a 3 _ by any applicant for a permit subjects the applicant to a civil penalty
ofnol more than Five hundred dollars(S500)J: ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of ilia property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do ilia work,and the structure Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cod:The Contractor's License Law does not apply to an owner of I
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himselfthrough ownemployers,provided iove-
m
mes arere "no"
o,
intended or offered for sale IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving 11m(he did not huild or.im - . - . .
- BUILDING USE
prove for purpose of sale.), r `I'.' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
O 1,oa owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contract.... to construct the project(Sec. 7044,Businesst LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: I'lie Contractor's License Law docs mit apply
rolan owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctorls)licensed pursuant to
the Contractor's Lienee Law. SEWER-SANITARY-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 Data WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 It a certificate of consent 10 self-insure, ) ZONING ENG.SITE NO.
or a eertificale of Workers'Compensation in,
or'a certified
copy therepf 3 0,Lab.C.
Policy No/♦ ompany
Certified copy is hereby'fumishad. FIRE SPRINK ENERGY T 24
Z Z Certified n y is fled wH tlm city aspec No division.
O Applican !_1c� Nin) MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ 0 ��'7�� � � PERMIT ISSUANCE 70.00
CC - CERTIFICATE 01'EXEMPTION FROM WORKERS' FLOODZONE A.L.U.C.
LCL U 7 CO.MPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ N❑ V❑ NF]Z 0t rhis section need not be completed if ilia permit is for one TOTAL
hundred lollurs($100)...less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
Uw become subject to ilia Workers'Compensation Laws of California.
y Daae Applicant ALTER OR ADD TO MECH. '5.00 BUILDING
} rn NOTICE*1'0 APPLICANT': If,after making this Cctlificatc of Ex-
F.. Z emption,you should become subject to ilia Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or tills pcnnit shall be dccmcd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSI'RUCHON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a consruc1mh lending agency for EXHAUST HOOD(WITH DUCT) 5.00
Ore performance of Ilia work for which this permit is issued(Sec. MICROFILM
.3097,Civ C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nddr HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.I agree 10 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 aunhortic representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree 10 save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue ag 'nst said City in consequence of the PERMIT ISSUANCE 10.00
r ting flIT pennil" MECH.CONT. LIC.NO, MECH.
7 TOTAL TOTAL
g ur ..'Applican jContra or Date
R INSPECTOR COPY