9043 /I�
u�APPLICANT TO FILL IN INFORMATtON•'WITHIN RED LINES - USE BALL P INT-PEN70 L
BUI IDI NG PROJECT I DENTI FICATI ON _ PERMIT NUMBER
MN �
DD' - APPLICATION & PERMIT 9043
ADD'
�� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEEs O 76_ PN ORS
E OUTLETS.SWITCHES-RECEP 10.00/1.00
Ic.No,5;3L[,31 LIGHTING FIXTURES 10.00/1.00
opw�glc S6J'n(0 I Q X �a PPLIANCES-RESIDENTIAL .4.00
°°..°011�"`�'PPII�J �f k,� r_� �I '�'-7�•'l0. PANELS 10.00 DATE OF APPLICATION
ARCHITECT UJJ ;JKT-� / / PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ARC" OR ENG. SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
zIP EMP. METER OR POLE INS. 20.00 „ _ •J
ADDRESS MOTORS SEE FEE SCH. �y (ll(•7,`^,'(P^
AS
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 T
a v I hereby affirm that I am licensed under provisions ol'Chapter Y
Z wa ISSUANCE DATE
n G m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H q Z P i s a and I'- n full for I ,,.A
IOy - Li _ `�:um ❑ ❑ ❑ IYI
0 m r Date ����,f rudor LLYl
¢w a OWNER-BUILDER DF;CLA TION JC' BUILDING PERMIT
X ;u. y I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
H u O j Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCEVALUATION $/FT.
Code:Any city Or county which retinues a permit to construct,alter, 10.00
¢m ELEC.CONTR. LIC.NO.
¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.
iL o u requires the applicant for Such permit to file a signed statement that TOTAL
A w m he is licensed pursuant to the provisions of the Contractor's License FERMI TO
H Z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
f q O Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ r m the basis for the alleged exemption.Any violation ofSection]031.5 STORIES TYPE CONSTR.
La 3 � by any applicant for a permit subjects the applicant ton civil penalty
of not more than five hundred dollars(55001.): ALTER-DRAIN& VENT-WATER (EA.) 5,00
❑ h 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 nr offered for sale (Sea 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 TOTAL ACREAGE
himseo
Stiff or through his own employees,provided that such inrproee-
mentsarenrlintendedorofferedforsale.If,however.the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 \
i` builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CDN PB Orbe,
❑ I,as owner of the properly,mo exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 El 0 El 11 D
and Professions Code: fhe Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contractoms)licensed pursuant to
We Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCE NNO,
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Dalc WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure.
or a certificate of Wllorrlk�ers'Co (ion Imsuraneq or a certified ZONING ENG.SITE NO.
Pr , t, F fin,;b4 N%e CGS
Z �❑y� Cerrttil�iegd copy is hereby furnished.
..yl FIRE SPRINK ENERGY T 24
� p Apican qK I I i YOU X-c.� J1 IN MISC.- REFER TO ORD. v N v NE]
CC h CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > (7041-NSA1ION INSURANCE PLG.CONTR. PLG.
CL O (This section need not be completed if the permit is for one w TOTAL Y E] NEI Y E] NE]
Z hundred dollars(SI00)or less.) 10
yy 1
CJ O 1 certify that in the performance of the work for which this per- QTY. M H "N ICAtL RMIT FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to s FEE
OU become subject to the Workers'Compensation Laws of Califurnia.
CL Date Applicant ALTER OR AD ,T ,Pi 5.00 BUILDING
>_ W NOTICE TO APPLICANT: If.alter making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCEVIA' 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=C.F.M.) 4.00 V
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5,00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.). ( HEATING UNIT(TO 10MICROFILM
0
Lender's Name ,000 B.T.U.) 8.00
Lender's Address V.E.H
UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the aboveTION 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 DOW H.P.or 100,000 B.T.U.) 6.00
„ hereby entioed representatives for ins rf this city to ecce upon theOMP (Over 100,000BTUI SEE FEE SCH. MECHANICAL /
above-mentioned property tativsp of
purposes.
(we),agree to Sava, indemnify and keep harmless the City of REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ma in any way accrue against said City in conseyu a of theSSUANCE 10.00
mn ing of this pormlf LIE.NO. MECH.
TOTA/ /O� TOTAL
gnazure of Applieantlt- nEraetrr Date �/
OFFICE COPY