09646 APPLICANT TO FILL IN INFORti&TION WITHIN RED LINES - USE BA POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI PERMIT NUMBER
6V •IL APPLICATION & PERN E 09646
ADDRESS
Olr.0 �Oa� // BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S �(� PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
[poNE
colurRAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.
NAME
VOW LIG7""�c LIC.NO / LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PANELS 1000 DATE OF APPLICATION
RCMrtECi PANELS (OVER 200 AMP) 2000 PLANCHECK FEE P.C.NO.
O
OR
ENGINEER
L.C.rvo. SIGNS TRANS. 3.00
ARCH,OR ENG. - SPECIAL CIRCUIT SOO PERMIT VALIDATION
.
ADDRESS PAID
ZIP EMP.METER OR POLE INS. 20.00 r Ery� egge
ADDRESS SNr$
ADDRESS MOTORS SEE FEE SCH. AUG F 1xyOJ
SERVICE CHANGE 20.00
SE o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 1�f �f „ylno
a, u v I hereby affirm that I am licensed under provisions of Chapter 9 GS5L N Cope
A CE DATE
n<N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH.
H w i Professions Code d license is in full fo a ffec
Oz o m - License Cla _ Lia Number ❑ ❑ ❑
o m F Datc �j1 Contra lot
y s BUILDING PERMIT
w
OWNER-BUILDER DECLARATION INFORMATION
wos MISC.- REFER TO ORD
3 LL H 1 hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
H i. o Law w for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to canstrucq.Iter,
6 Q 0 improve,demolish,or repair any structure,prior W its issuance,also ELEC.CONTR. LIG NO.
ELEC. I
D 2 requires II1C applicant for SIICII permit t0 f1IC a signed statement that IOTA - �/ pERr1aIT:O
K
m LL he is licensed pursuant to the provisions of the Contractor's License rL/
rii
Law(Chapter 9(commencing with Section 7000)of Division 3 of the �`F r�`
- a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ;m by any applicant lot a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S5000.):
01,as owner of the property,or my employees with wages as BACK F LOW 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,COND. 5.00
Code The Contractor's License Law does not apply to an owner of
property who builds or improves fiction,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided that such building improve-
merits
are not through
or offered emor ployees.
t.provided
that however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build 11r int' R IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am 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 Contractors Liamse Law does not apply
ro.,1 ..net 1111 property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCELNO.
❑ I amt exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 6.00
re."m
Owner Uare WATER SYSTEM 5.00
ACC.DATE ACC FILE NO.
WORK E:RS'COMPENSATION DF.CLARA'IFION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.)./ C ��
I'olmy No. Cm pany �
Cl Certified copy ill ereby urnished. FIRE SPR INK ENERGY T24
Z Z ❑ Cerrif y fl• Ith th tY inspection division. - REFER TO ORD. YE] N❑ Y N�
MISC.
O Applicanto--e� 1a0-
CC D CER1'IPICATE 01:ExEm PTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > C04IiNSAT10N INSURANCE PLG.CONTR. ❑C.No. PLG.
d O (This section need not be completed if the permit is for one TOTAL y[:] N[3 M ❑ N�
D Z h undred 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 F our 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. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} y NOTICE TO APPLICANT: If,after making this Certificate of F:x-
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 AIR HANDLING UNIT(TO 10 GF.M) 4.00 FEE
V such io
provisns or this permit shall be deemed rcvnkcd. A00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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(Sea HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
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 state 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 rhe BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs cold expenses which CONST.TAX
may in any way accrue gains said City in consequence of the PERMIT ISSUANCE 10.00
grantis ing of MECH.CONT. LIC.NO. MECH.
Aga` �J TOTAL TOTAL
Signature of Appllc.nl/Comructor -D,
OFFICE COPY