9491 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
BDILDING APPLICATION & PERMIT
9491�1
AODRE55 {J,4 FV]] 1!
y BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 91
PLAN CHECK VALIDATION
n
AMC PHONE QTY. ELECTRIC PERMIT FEE
• L_p ,
N°
MER T s OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS'RESS - APPLIANCES-RESIDENTIAL 4.00
O
PHONE PANELS 10,00 DATE OF APPLICATION
OR
RCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADD Ess ENGSPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID
ASMOTORS SEE FEE SCH.
ADDREDDRESSS p p
SERVICE CHANGE 20.00 AUG G 1-11 1.985
w o O LICENSED CONTRACTORS DECLARATION I TEMP.POLE 30.00 /� .{Q
a mo u I hereby affirm that I am licensed under provisions of Chapter9 1iISAfIgQjrypno
y
¢ w (comnlevming with Section 7000)of Division 3 of the Business and
wBLD ELECT. PLG. MECH.
r D z Professions Code,and my license is in full force and effect ❑ ❑ [Jz o m - License Class Lie.Number
oDate Contractor
a m BUILDING PERMIT
Se ¢o u OWNER-BUILDER DECLARATION INFORMATION
E
; y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u 0 ¢ Law for the following reason.(Sec.7031,5,Business and Professions VALUATION $/FT.
r- Code:Any it rmunt which requires PERMIT ISSUANCE 10.00
yu yo yw quires a pernit toconstrmtalter, 0w �
¢ ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. �!/)
D IC or
requires the applicant for such permit to file a signed statement that TOTAL w PERMIT TO w" he is licensed pursuant to the provisions of the Contractors License
Uzi
Law(Chapter 9(commencing with Seer ion 7000)of Division 3 of the
pro-- Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
¢F o the basis for the alleged exemption.Any violation of Section 7031.5 RIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of Rot more than live hundred dollars($500).):
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation.will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 71144, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himselforthrough his own un red for
provided that such improve- - .
mems are not Emended or employees,
for saleIf,however,the building GAS'EA.SYSTEM-1 1NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . - . .00 the owner- GAS EASYSTEM OVER 4 (EA) 2
builder will have the burden of proving that he did not build or ire. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 - RE IND CON Pe Omer
❑ I,as owner of the property,am exclusively contracting with . .
E] ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOHS PARCEL NO.
and Professions Code:The Comtrletoi s License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt hinder Sc<. .B.&P.C.for this WATERHEATER W/VENT 6.00
\ reason"r '- ..
�( Owner e� Dale _g/1Ju$y WATER SYSTEM 5.00 Ace.DnrE ACC.FILE NO.
WOR :RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 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 thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Cerlified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ NO
fr T CERTIFICATE 01:EXIiMPT10N PROM WORKERS' PERMIT ISSUANCE .L 10.00 FLOOD ZONE A.L.U.C.
W ? COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not be completed if tire �e permit is for one TOTAL Y NE] V 0 NF]
hundred dollars IS 100)or less.) I F V
U O 1 certify that in the perl'unnance of the work I'or which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person io any manner so as to
O w become subject to the Mbrkars'Comprnsation Laws of California.
Date Applicant BUILDING
} Do NOTICI7 TO APPLICANT': If,after nmking this Certificate of Ex ALTER OR ADD TO MECH. 5.00 o
F" Z
mi 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 10,1300C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE D
I hereby affirm (her then is .'Construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
309,7,Civ.CJ. y HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
.information is correct, 1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Ove.tl10,0008TU15EE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino aSmhhsl 11861hUC],Jlhdglllcuts, Cn$(s and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grantingofthis permit MECH.CONT. LIC.NO. MECH.
\� TOTAL / TOTAL
1l $ignat a pp tear on mcmr Date
INSPECTOR COPY