9265 API ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-L-01 NG PROJECT I DENTI FurATim9ft PERMIT NUMBER
,NG OU
APPLICATION & PERAP
ADDRESS
OST "/Da�a3 ILDING - ELECTRICAL-PLUMBING-MECHANICAL 9265
OWNER'S V PLAN CHECK VALIDATION
NAME17 QTY. ELECTRIC PERMIT FEE
NA ACTe- OUTLETSMO -SWITCHES-RECEP 10.00/1.00
ryOY/f A & LIC N LIGHTING FIXTURES 10.00/1.00
no ESSTOR$ eU Lf ✓d 'I PPLIANCES-RESIDENTIAL 4.00
L C PROrvE ii PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
NGINEEP
LIC.NO, SIGNS TRANS. 3.00
ADD Ess END. PERMIT
CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. PAID
ADDRESS
SERVICE CHANGE 20.001 )
'0 o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00 "�� ^' ����
u UI bereby affirm that 1 am licensed under provisions of Chapter 9 ISSUA C DATE .
m<w (commencing with Section 7000)of Division 3 of the Business and BLDG. )' ECH.
H w z Professions Codq an }�Llicense is in full for fc
z
.0. - License Class-(�-"`J Lic.Numbct t U - ❑ ❑ ❑
9 r )ate Contractor
¢ Y E a BUILDIN PERMIT
¢ Ic w¢ OWNER-BUILDER DECLARATIONINFOR ATION
w 3 u n I hereby affirm that I am exempt from the Contractor's License
MISC.= REFER TO ORD
w o¢ Law for the following reason.(Sec.7031.5.Business and Pmfasions PERMIT ISSUANCE 10.00 VALUATION SIFT.
H - J Code:Any city orcounty which requires a permit to construct.altar,
2 ¢<p improve,demolish,or repair any struclure,prior to its issuance,also ELIC.CONTR. LIC.NO. ELEC.
es n requires the applicant for such permit to file a signed statement that TOTAL nFLOOR
IT TO
w m he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9(commencing with Section 7000)ofDivision 3 of the
Business and Professions Code)or that he is exempt therefrom and OTYPLUMBING PERMIT FEE
the basis for the alleged examsubje Any violation fSaiqirm703L5 malty TYPECONSTR.
d ; by oty applicant fore permit dollars thcupplicam tuacivilpenaltyALTER-DRAIN&VENT-WATER (EA.) 500
of not omni than five hundred rty.o 1my to )'.❑ I,as owner at'themi,will d tt or my employees with re is notBACK FLOW PROTECT. DEVICE 4.00 RES.UNITS
as
their sole compensation,will(S the work,and the structure is notintended or offend for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply lD an owner of
himself who beiWs or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 TOTAL ACREAGE
inents
himself Or through his own employees,provided thin such imprwe-
menuarenot intended oroffered for sale.ll'.however,the building GAS-EA:SVSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner . .) 2.00- GAS-EASYSTEM-OVER 4(EABUILDING USE
builder will have the burden of proving dial he did not build or im- E IND CON PB Omar
Prove]or purpose ol'suleJ' INDUSTRIAL WASTE INTER. 30.00 ❑ 11 ❑ ❑
❑ 1,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 Contractor's License Law does not apply
to an owner of property who builds or o plroves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts ler Such projects with x contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt under sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC FILE NO.
WORK ERS'COMPFNSATION DECLARATION 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(Sac.3800,Lab.C.).
Policy No. C ny- -
Q ❑ C�f c y� re nisheJ. FIRE SPRINK ENERGY T-24
Z Z er ied a ri o itv inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O Applicant Y N V N
� y CIL RTIFICAT'E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
ILL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section scud not he completed if the permit is for one TLOTAV[:] N❑ Y C] N❑
=) Z hundred dollars 1S 100)or less.)
00 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
UJ Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: II',after making this Certificate of Ex-
r Z 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 10=171F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IQODOCF.M.) 6.00 SEISMIC FEE
1 hereby affirm that then is a construction landing agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.C.). _
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and countyPLUMBING
ordinances and state laws ralmir, m building construction, and BOILER-COMPOH.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000BTU)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 and expenses which CONST.TAX
may i any ace agains(Said City in curse mare of the PERMIT ISSUANCE 10.00
gm n f p / MECH.CONT. LIC.NO. MECH.
��y�Ar TOTAL TOTAL /
Signature of coal Cont`ract`or` D* ( /
\ OFFICE COPY
� I