9082 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADORESa_
zzf_ l �, 1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9082
OWNERS V cs PLAN CHECK VALIDATION
N ME
• /n• / DTV. ELECTRIC PERMIT FEE
d '` < PRUNE rJ -z
DgNERACTORs _q� t' UTLETS-SWITCHES-RECEP 10.00/1.00
rQ-� LIC.NO,11S 'y 7 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
3 rt PHONE^ FjZ PANELS 10.00
DATE OF APPLICATION
ARDRRK PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS END. SPECIAL CIRCUIT 5,00 O PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANT'S
AooREsy MOTORS SEE FEE SCH.
M
SERVICE CHANGE 20.00 -�
, 02
0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢t I hereby affirm that 1 am licensed under provisions of Chapter 9
y a n (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r 7 2 Professions Code d m license is in full force eL - BLDG. ELECT. PLG. MECH.
o i H o License Class 4 Lic.Number El CSI ❑
,,,r j Date,"./ jecaContractor ILEI
W x M st J OWNER- R � BUILDING PERMIT
_ ¢ w U BUILUIiR DECLARATION INFORMATION
E
;'w I hereby affirm that I am exempt from the Contractor's License MISC.- FER TO OR
u O¢ Law for the following terser.(Sec.7031.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit to construct.alon
IF
¢ Q improve,demolish,Dr repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. '1 _
m¢ requires the applicant for such permit to file a signed statement that TOTAL Or'F7 PERMIT TO
n w he is licensed pursuant to the provisions of the Contractor's License
F z aLaw(Chapter 9(commencing with Section 7000)of Division 3 of the EL-0"C7,4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
¢ Ole basis for the alleged exemption.Any violation of Scetion 7031.5
by any applicant for a permit subjects the applicant toa civil penalty STORIES TYPE CONSTR.
of not more than five hundred dollar,($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the properly,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. 7044, and
and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or Improves Ihercun,and who dues such work• FIXTURES-PER
IXTURES-PER TRAP 5.00 Set FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The 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 a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I ant exempt under Sec. ,B.&P.C.for fills 6.00
reason WATER HEATER W/VENT
Uwner Date WATER SYSTEM 5.00
ACC.DATE ACF FILE NO.
WURKIi RS'COM PENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,'f b.C- ,y-+
Policy No. Company T
Z ❑ Certified yl is
nis S II-3d
,�� FIRE SPRINK ENERGY T-24
Z Z ❑ Cert' Copy a tiled w'Ih tl 'II pec Hun di i to .
Applicant_ MISC.- REFER TO ORD. Y C] N[D Y ❑ NE]
~ O PERMIT ISSUANCE
w CERTIFICATE OI'EXEMPTION FROM WORKERS' 10.00 FLOOD ZONE q.L.U.C.
LU > COhIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N CD Y❑ N
Z hundred dollars t$100)or lessI
U O 1 certify that h the to employ
of fie work for which this per- TY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person iu any manner so as to
C W become subject to the Workers'Compensation Laws of California.
NOr Applicant
C. 5.00
>- C. NOTICE 70 APPLICANT: It after making this Certificate of Ex- ALTER OR ADD TO MECH. BUILDING -
F ? emptier,you should become subject to the Workers'Compensaiou APPLIANCE 5.00 PLAN CHECK
provisions of fie Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=12-F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.RM.) 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 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state(hat the above VENTILATION FAN (SINGLE)• 4.00 information is correct. I agree to comply with all City and county
ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby authorize representatives of this city to enter upon file
above-mentioned properly for inspection purposes. BOILER-COMP(Over 110,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jmdgnurits, costs and expenses which CONST.TAX
ma in any way accrue against sal City in consequence of the PERMIT ISSUANCE 10.00
tanto ofthi petmil' MECH.CONT. LIL.NO. MECH.
CC"
-
S" ore of Applicant Comractot Date TOTAL TOTAL
OFFICE COPY