9192 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
.�, BUILDING OORE55
9192
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/yd✓C/`f iE� cTEF/.�C- ILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow tIaN, PLAN CHECK VALIDATION
NAME Y7 �-O OTY. ELECTRIC PERMIT FEE
I� PHONE
co AS UTLETS-SWITCHES-RECEP 10.00/1.00
o y LIGHTING FIXTURES 10.00/1.00
nADNT 's AD o"'
4.00
P PANELS 10.00CHEOF APPLICATION
RC
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE V.C.NO.
OR
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ADD'Ess eN¢ SPECIAL CIRCUIT 5.OQ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 ^ ,/��
ADDRESS MOTORS SEE FEE SCH. (\(711L6/��li'
ADDRESS
SERVICE CHANGE 20.00 -7/
�O
0 0 o LICENSED ACTORS DECLARAT ON TEMP.POLE 30.00 A
a u u 1 hereby all l,Ocn under Is so Chap
ISSUANCE DATE
m Q a Icontmcnci m 0 Ui ' th�e yBpu(�siness anti BLDG. ELECT. PLG. MECH.
H m i Professio a by is hsi arcs 'ffwaln)� '/ ��
Z o y- LiceI s Lia nnM1 7.J ❑ ❑ ❑ ❑
a w Ca r r
a u f P,L�I.pING PERMIT
x Ix w ¢ OWNER-BUILDER DECLARATION Ih�111UJPPUU RMATION
Lao A " REFER TO ORD
I hereby affirm that 1 am exempt from the Contractor's License MISC.-
u O a Law for the following reason.(Sec.7031.5.Bushossand Professions ( VALUATION �5 $/FT.
r _ PERMIT ISSUANCE 10.00 1N� T-+ I, 1L01
is Code:Any city or coumy which requirese permit to construct,altar.
i Q Q improve,demolish.or repair any 9nmture,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
al
LL requires the applicant for such permit to file a signed statement that TOTAL PER MI T
u w$ he is licensed pursuant to the provisions of the Contractor's License ^A' pQr{Ind
Hit Law(Chapter 9(commencing with Section 7000)of Division 3 of the la1Y Ns J(/b.,LC
- ¢ Is,does,and Prssio
ofens Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ;m by any applicant for a permapplicant it subjects the applicano a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55000.):
❑ 1,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 I'or talc (See. 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 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
: ments are not intended or offered for sale.IC however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or inhprovement 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 or inh-
proveforpurposeofsale). 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,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 am owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts'for such projects with a contruclohfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec .Ii.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKHRS'C PENSION :CLA WATER TREATING EQUIP. 5.00
I hereby al Lr f LO sent to self-insure, ZONING
or a Lett,llon Ica f or 'I Iiol nu,sumnc or u certified
ENG.SITE NO.
copy the 3
Polic o
O ❑ C d1 rs r n FIRE$PRINK ENERGY T-24
Z Z ❑ Ce p de sly' mspeclion division. MISC.- REFER TO ORD.
O App v ❑ N❑ v ❑ N❑
ir y iR -1 '1'17 0171 XIiMPIION FROM WORKERS'
PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
>_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C 0 This section need not be completed if the permit is for one TOTAL Y El IN❑ Y❑ N❑
::) Z hundreddollars(S100)orle..)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any Person in any manner so as to
O
U beconm subject to the WorkL,,Con..ensation Laws ol'California. /
w DD TO MECH. 5.00
RBUILDING �-_J-0
a ule Applicant ALTER OR A
} 0 NO"FICE TO APPLICANT: If,after making this Certificate of Fx-
F Z emplion,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 10,000C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000C.F.M.) 6.00 SEISMIC FEE �7J
1 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.Or 100,000 B.T.U.1 6:00
hereby authorise representatives of this city to enter upon the
BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned props y for inspection purposes.
(We) agree to inde ify and kce hornless the of MISC.- REFER TO ORD.
Cupertino ag mbilit' . it is, s hd ex .es ich PERMIT ISSUANCE 10.00 CONST.TAX
may in a ace gains( Lid i co (Joe of the
grana per MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sib tar pplicant/Contractor a e
OFFICE COPY