C9500 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION . PERMITNUMBER
BUILDING APPLICATION & PERMIT 9500
ADDRESS
/ ` 6 16SSe o OY BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S IM CHECK VALIDATION
NAME
-� �2/ O7V. ELECTRIC PERMIT FEE
De,
PHONE b
CONTRACT 'S
NAME/ r L OUTLETS-SWITCHES-RECEP 10.00/1.00
GJ/s /?001r%/✓ LIc. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR V
AIFIESSPPLIANCES-RESIDENTIAL 4.00
A RE$$/
9;J / /p1i HOrvE�/ / PANELS 10.00 DATE OF APPLICATION
ARCHITECT V PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ErvG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
SpDREss
.G p L✓L SERVICE CHANGE 20.00 4A /
O 0 0' TEMP.POLE 30.00
Foo LICIiNSEU CONTRACTORS DE LA RATION
Qu w 1 hereby affirm that 1 am licensed muder provislmrs of Ch:mte,9 l u
H a e, (commencing with Section 7000)of Division 3 of the Business and e. B E MECH.
H y z Prolessions Code,and y 'cense is in full fur' a ffecl p QI� ITI�'r e-
z 0 m - License Class Lic.Number J ❑ ❑
Q z H w Dalc�Con tracmr F
s � L MIT
¢ ¢w OWNER-BUILDER DECLARATION INFORMATION
od MISC.- REFER TO OR
X u y 1 hereby aflir n thin I am exempt from the Contractor's License VALUATION
Fu04 law for the followingrexson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Anycityorcounty which reyuiresa permit to construct,alter,
aimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
lo
- O a, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n ec m he is licensed pursuant to the provisions of the Contractor's License �(
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ol'the
- a Business and Professions Code)me that he is exempt therefrom and GTY. PLUMBING PERMIT FEE , 1
H the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
d;� by any applicant for a permit subjects the applicant toa civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do Ilia 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 thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such intprove-
mentsarenorintendedorofferedforsale,idtd tats Om building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON Pe Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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 docs not apply
to
un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects will,it contractors)licensed pursuant to
IIIc C'ontractor's License Law. SEW ER3AN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSAT1ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell'-insure. �- O ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a c'rt flied
copy
cy No. f(Scc.3g00,Lab.C.).n ff 2 a JI
Policy No. is I cre nys
Q ❑ Ce cop issfiled furnish the FIRE SPRINK ENERGY TYA
Z Z ertified copy Is filed With the city inspection division.
O Applicant MI C.- REFER TO ORD. r❑ N❑ v ❑ IN
♦- y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
� CfSR1'I PICCOM COMPENSATION
ION PROM WORK ERS'
W � COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O ('this section need not be completed if the permit is for One TOTAL Y❑ N Y ❑ N❑
2 hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work bu which this per- GTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL h mit is issued,1 shall not employ any person in any manner so as to
U become subject to Ilia Workers'Com nsation Laws of California.
w Date Applicant PL BUILDING
o. ALTER OR ADD TO MECH. 5.00
} W NOTICE 1'0 APPLICAN"C If,after making this Certificate of Ex-
? enmtiun,you Should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wi01 FEE
U uch pfovismits or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.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. MICROFILM
3097,Co.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 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-IxNvN(3 H.Ro-100,000B.T.U.) 6.00
hereby authorial, representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. 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 in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran g this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signaureof pylic' t/ ontm r - Date
OFFICE COPY