09687 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIbDI NG PROJECT I DENTIAPERMIT NUMBER
son- ING - APPLICATION & PE T
ADOREss09687
96 8 7
�. STweNs CveeK B u�., BUILDING - ELECTRICAL-PLUMBING-MECHANICAL J
OWNER'S •. - PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
TR b r
HONE
1 1
CONTRACTORS
sy`c�MEz UTLETS-SWITCHES-RECEP, 10.00/1.00
✓LV uc.No. LIGHTING FIXTURES , 10.00/1.00
CONTRACTOR'SPPLIANCES-RESIDENTIAL
'' 4.00 -
DDRES
1 r PHONE�'I 3 PANELS 10.00 DATE OF APPLICATION
ARCHITECT ,5/TA. T CEJ F
5119 „ • ' PANELS 200 AMP) ', 20.00 PLANCHECK EE P.QNO.
OR U lYa�-
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5.00 - •PERMIT VALIDATION
'rev rrEMP.METER OR POLE INS. 20.00
Ars
ADDRESS
- - MOTORS ®E'FEE SCH. '
DRE55 '
SERVICE CHANGE. 20.00 )
w
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE q 1913%0.00
a ow I hereby affirm that I am licensed under provisions at Chapter 9. IBSUAN E DATE
y a y (commencing with Section 7000)of Division 3 of the Business and n . BLDG. ELECT. PLG. MECH.
F N Z Professions Q y license is in full R, ,�If c Q7 1 ❑ ❑ ❑
zD 0 m o License Class�_�Lk.Number p�gy,`��_ ��sZ� __�� ,
F w r j Date 1/Jl',$s Controcmr_fL�ZI[Q'�JSG ,
ar ¢T _I- -l. OWNER-BUILDER DECLARATION - BUILDING PERMIT
F
; a- N I hereby affirm that I am exempt from the Contractor's License
- MISC.- -'REFER TO ORD INFORMATION s
LL O¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.
- PERMIT ISSUANCE 10.00 0
Code:proe,y nolish coo my whiny structure p prior
t u is issuance,also ale t ¢ improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. UC.NO,, ELEC. Ob '
wO T requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License � /
r Z i• Law(ChuPter9(commencingwith Section 7000)of Division 3 of the M
1 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IGH $ the basis for the alleged exemption.Any violation of Section 703 L5 - _ STORIES TYPE CONSTR. I
i 3 _ by any applicant for a permit subjects the applicant to a civil penally ,
of not more than five hundred dollars(S500).); ALTER-DRAIN&VENT-WATER (EA.) 5.00
O I,as owner,of the property,or my employees wills wages its BACK FLOW PROTECT. DEVICE- 4.00 Dca GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered fur sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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,vI-oDR AREA TOTAL ACREAGE
himself re through his own employees.provided that such improve-.cuts are not old or within sed one or yearn If,however.the the owner. GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one yngthacompletion,the owner- GAS-'EA.SYSTEM-OVER 4'1 EA.) 2.00 _
builder will have the burden of proving that he did not build or int- BUILDING USE
prove 11,as opom of saleJ' INDUSTRIAL WASTE.INTER. ' '30.00 RES IND CON PB Omm
❑ d as owner of she property,he exclusively. 7044, ung with ❑
Sod Pod contractors m construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
and n owner of Code:l'he Contractor's License Law Woes ons apply - -
to tr owner of h projects with
builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such cense L wish n contrautorf sl licensed pursmms In SEWER-SANITARY-STORM EA.200f1/10.00
the COI tractors License Law. TRACT NO. PARCEL NO.
❑ .I ani exempt under See..,BAP.C.for this
rWATER HEATER W/VENT 6.00 '
l.vol
Owner Dute WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORK ERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to rel Linsuty,
or a certificate or Workers'Compensation Insurance,or,a certified ZONING ENG.SITE NO.
copy the °' 3 000,L.1bC
I'oliLY ZXT-�-IUSompany bX2z 1153 -
O. 1p]S Certified copy is hereby furnished.• FIRE SPRINK ENERGY T-24
z Z Cersifieyyy copy is filed
impection division.
f- O Apphuant./1 / MISC.- REFER TO ORD. Y E N Y ❑ ND
CFRI'IFICATI>OFIiXEMPTION FROM WORKERS'. PERMIT ISSUANCE 10.00 FLOOD ZONE' A.LU.C.
W COMPENSATION INSURANCE PLG:CONTR. LIC:NO, PLG. -
CL Z (This section need not he completed if the permit is for One I TOTAL V❑ N❑ V NE]
hundred dollars(S I OO)or less.)
L) O 1 certify that in lite performance If the work for which this per- FEE SUMMARY
- QTY. MECHANICAL PERMIT FEE
LL F- mit 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.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of she labor Code, you .,loss forthwith comply,will, FEE
V such provisions or this permit shall be deemed revoked.' AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE- '
I hereby affirm that there is a construction lending agency lin - EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
[.count's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC EP
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 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 autlmrize representatives of this city to enter upmi Ole BOILER-COMP(0.,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•ugainsl liabilities,judgments, costs and expenses which CONST.TAX
Ran in any way accrue a�amm �ld in conseyucne of the PERMIT ISSUANCE 10.00t g0 IbisPtrmiLQ CH.CONT. LIC.NO. TOTALTOTAL
Signature o Applica I/ConDate - -
OFFICE COPY -