8565 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LOI NO PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
J1AJ141P�q&54A BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 856
OWNER'S
NAME PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
• PNONE
CONTRACTORS j��, UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NtA- LIGHTING FIXTURES 10.00/1.00
nooMSS rolls PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 - DATE OF APPLICATION
ARRC HITECT` PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
Ars MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00
,02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a i W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a a (commencing with Section]000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH.
F D i Professions Como nse is in full for 1 eff-c . [1 ❑ ❑
o 04 Ly
W License Class Lic.Number V
Date Contmeto _
a x - BUILDING PERMIT
¢ as OWNER-BUILDER DECLARATION
o a o - INFORMATION
K
; r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a. �n VALUATION $/FT.
ru04 Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00
w i Code:Any city or county which requires permit to construct,alter,
¢ R aimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. .
to
w m a0 requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
F z¢ Law(Chapter 9(commencing with Section 7000)of Division3 of theG�`-,/T/
i D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
tX r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.).5,00
of not more Ihan five hundred dollars(5500).):
❑ 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,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
himself or through his own employees,provided that such improve
mems are not intended or offered for sate.If,however,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have she burden of proving that he did not build or im- RES IND CON PB OrM1er
1,as o
prove of sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑ ❑
❑ I,as ownernee of the property,em 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 a contractor(s)licensed pursuant 10 SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ Inco exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 6.00
on
Owner Date WATER SYSTEM 5.00
ACC.DATE ACO,FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. - 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thef{ Lab.C.
Policy N& mpany
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z pfi2 fried cop with the city inspection division. ❑ ❑ ❑ ❑'
O Plic.ca /�'p MISC.- REFER TO ORD. Y N Y N
D: N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
IL Z( This section need not be completed if the permit is for one TOTAL Y[-] N� Y IN
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any Person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ W NOTICE TO APPLICANT: If,after making ibis Certificate of Ex
F 2 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 shall be deemed revoked. AIR HANDLING UNIT(TO .M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F.M•)�6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD( •! .00
the performance of the work for which this permit is issued(Sec. r� MICROFILM
3097,Civ.C.). HEATING UNIT IT 00,000 B.T.U.1, 6.00
Lender's Name HEATING UN IT IOVE .50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN ( LE) 4.00
0 information is correct. I agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building consttuction,'and BOILER-COMP 13 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(Over 100,000 BTU)SEE FEE SCH. MECHANICAL pZ
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE' 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran' Of this pepp MECH.CONT. L MECH.
` \ TOTAL TOTAL
Sigmatureof9ppliallinICNotri m Date
OFFICE COPY