09642 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONBDILOING
PERMIT NUMBER
/ APPLICATION & PERMIT
'7= AooSS
IBgO00 No IN C,, -C RJ. 09642
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
. QTY. ELECTRIC PERMIT FEE
yg TO PHONE257 IO
CONTRACTOfl'S
? NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
/ G wel�. LIC,No. -5 y I LIGHTING FIXTURES 10.00/1.00
nDDRESS Tons yI PPLIANCES-RESIDENTIAL 4.00
Q �0/r1T Fy PHONE O PANELS 10.00 DATE OF APPLICATION
RRPLAN CHECK FEE
ARCHITECT PANELS (OVER 200 AMP) 20.00
OR
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE '20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a 0 1 hereby affirm that I am licensed under provisions of Chapter 9
y Q a. (commencing with Section 7000)of Division 3 of the Business rind ISSUANCE DATE
0 H Z Professions Code a d my license is in full force-5 effect BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
z o w,- License Class Lic.Number S 3 1&/
o N F w Data Contractor
a w a OWNER-BUILDER DECLARATION
BUILDING PERMIT
is o a - INFORMATION
X 5 LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H 0< Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
y � Code:Any city or county which requires permit loconstruc[,alteq
10.00
er 4 O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O
n LL inquires the applicant for such permit to file a signed statement that TOTAL
se $ he is licensed pursuant to the provisions of the Cont rac l oris License PERMIT TO
w. Law(Chapter 9(com me nu ing with Sect ion 7000)o f Division 3 of the � �
4 O Business and Professions Code)or Thar he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ I- the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,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,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work Z FIXTURES-PER TRAP 5.00 IO SQ FT.FLOOR AREA TOTALACREAGE
• himself nts re through his own employees.Provided that such int building
m improv not mens tended w thinoffered
one year
If,however, hetthe owner
GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement will
mem is sold within one yea of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving thin he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
L . .
❑ as owner of the property,am exclusively contracting with El 0 0 0 Q
licensed contractors m construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
toProfessions Codegrope The Contractor's License Law'th docs not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA,) 1,00
contracts for such projects with a L<mtrmtogsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-ST 200ft/10.00 TRACT NO. PARCEL NO.
❑ l an,exempt under Sec.-,B.&P.C.for this
reason WATER HEATER W/VENT 6.00 r
Owner Date WATER SYSTEM y 5.00
ACC.DATE ACF FILE N0.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, City
p
or a certificate of Workers Compensation Insurance,or a certified nal Of Co ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.I
Policy No. Company
O ❑ CertiEedcopyish,,eb fumished.WL OV FIRE SPRINK ENERGY Rio
Z ❑ Cert ific copy is file y ith the yly inspe!t��&�o
FO Applicant M C.- REFER TO ORD. YE] N� Y [3 N❑
CC y CER 'ICAT OF EXEMPTI N FROM WORKERS' PERMIT ISSUANCE 10.00 ID FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO.
CIL o (This section need not be completed if the permit is for one TOTAL 2-0- Y 0 NE] Y ❑ NEI
::) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I slhall not employ any person in any manner So as to
O m become subject to the Workers'Compensation Laws of California.
a
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
}.ED NOTICE TO APPLICANT: If,after making this Certificate of F,x-
I- Z emption,You Should become subject to the Workers CompensationApp APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M,) 4,00 FEE
CONSTRUCTION LENDING ACENCY AIR HANDLING UNIT(OVER IO,OWCF.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 500
th .
e performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and ,are that the above - VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING e
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.RoI'100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tum
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
South of this permit MECH.CONT. LIC.NO. MECH.
t x-29-8 TOTAL TOTAL
Sign re of plicant/Contin Date
OFFICE COPY