8869 APPLICANT TO FILL IN INFORMATION WITHIN-,RED LINES - USE BALL POINT PEN ONLY
B 1 LDI NG PROJECT I DENTI FI 'r31\ - PERMIT NUMBER
I� PPLICATION & P IT
9uILDl -
ADDS s BUILDING ELECTRICAL-PLUMBING-MECHANICAL y
r Ow ER /0. /� PLAN CHECK VALIDATION
NAME ��/ / / •NONE"'f/�Q
QTY. ELECTRIC PERMIT FEE
!� coNTRACToes UTLETS-SWITCHES-RECEP 10.00/1.00
NAME _ AAAA /� !A/^ ? y
Q /rL C N�G,D Cie ND. /� LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES PPLIANCES-RESIDENTIAL 4.00
ADDRES•^S/ //� { n r S ` �1 '
/5(! (/I✓'J��V�((LW PHO E 2 5-�a PANELS 18.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR ,o/'�9GT«QN �SSOG:IT PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AODRE65 ENG SPECIAL CIRCUIT 5,00 •PERMIT VALIDATION
EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. PAID,
ADD E$ P�l T
• _,Vr g6�6� S.
�.S SERVICE CHANGE 20.00 jlnp
o O O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 APR Q ��®�
F i W I hereby affirm that I am licensed under provisions of Chapter 9 IS CEO E
(commencing with Section 7000)of Division 3 of the Business and BLD MECH.
F m i Professions Code and n licca se is in full force lold,4•f ct El
LTJ�
z o o - License Class - Lit.Number,._,(_!__/ Qr
a L D Dam �.O�_'G-Con Nuctor_U_C•1T�
a y s BUILDING P MIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORM TION
a Da " MISC. REFER TO ORD
w g ic i- I hereby ullirm that I am exempt from tire Contractor's License VALUATION $/FT.
ac IL
Law for the following reason, 7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
ic ir Q p improve,demolish,Or repair Iuly structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
- CLL requires the applicant for such permit to file a signed statement that TOTAL PE T TO
n w m he is licensed pursuant to the provisions of the Contractor's License
HiLaw 9(commencing with Section 7000)of Division 3 of the
Q
s i D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 I STORI S TV CONSTR,
by any applicant fora permit subjects the applicant toa civil penally ALTER-DRAIN IEA.) 5.00 �•
of not more than Five hundred dollars($500)):
Cl I,as owner of tete pnnperty,lir my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do tine work,and the structure lis not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 40 Ci
Code:The Contractor's License Law docs not upplY to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 O SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such int Provr
ments are not intended or offered for sale.If.Imwever,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of mpletion,the owner-
co GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 L euaolNG USE builder will have the burden of prnving that he did nut buil)or int- RE$ INo N PS Oma.
prove for purpose resale). INDUSTRIAL WASTE INTER. 30.00 1:1❑ 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 ASSESS $ ARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who ,..� LAWN SPRINKLERS-OVER 5(EA.) 1.00 ---
contracis for such projects with a contruaor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. J TRACT N . PARCEL NO.
❑ 1 um exempt under Sm. ,BL&P.C.for this z
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORT:L'RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I' I hereby affirm that I have a certificate of consent to sell=insure,
.,.certificate of Workers'Com ensLatio t Insure 0.or a L�qJr ti(ind ENG.SITE NO.
copy thereyf f5ec. 0,Lab.C.(j{�J l A .\J '1404 11
Policy NoSLF)4.�5_CompwryS
Q Cl Certified copy is herby farm d. Z IRESPR IN ENERGY T$4
�.p�CcRifi� L�Y�}S d will 11 t inspection Division.
Z Z A(plRam�lL7l.-VI�+� ��`y MISC.- RE RTO ORD. Y C] N� Y F N0
jr S2 CERTIFICATI!OF :XEMP`rION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. O' f1 L Y N V N
d O This section need not be completed if the permits for one TOTAL O O O
Z) Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U beconse subject to the Workers'Compcivation Laws of Culdcorda.
a Date-Applicant ALTER OR ADD TO MECH. 5.00 'BUILDING
>_ lin NOTICE'r0 APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of [lie Labor Code, you must forthwith comply with FEE
U such provisions m this permit'hall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT IO VER 100,000 B.T.U.)9.50 ELECTRIC
Lender''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 BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(OVe,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 and expenses which CONST.TAX
IRS
in any way accrue against said City u unsequence of the PERMIT ISSUANCE 10.00
gsanpng Of this permit. MECH.CONT. LIC.NO. MECH.
1 r ' r TOTAL TOTAL
gnature of Applicant/Conntt-r-actor Dated
OFFICE COPY