09670 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
097
Ap RES 5 'We�Ote L
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 6
wry R' PLAN CHECK VALIDATION
NAM QTY. ELECTRIC PERMIT FEE
PHONE Z / 9
NAME acTORs 'T,
OUT ETS-SWITCHES-RECEP 10.00/1.00 ��7_
lox 1 Y f f JVAIC.No. LIGH I -G FIXTURES 10.00/1.00
ONTRAGTona PPLIANCES-RESIDENTIAL 4.00
AODRESS
oePHOrvE ,PANELS 10.00 DATE OF APPLICATION
'OPCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
,ENGINEER
uc.NO. \-, SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP 1 EMP.METER O POLE INS. 20.00
ADDRESS TS a MOTORS _,11, v SEE FEE SCH.
•/ SERVICECHANGE 20.00
�¢ � TEMP.POLE 30.00 f� 0
Foo LICENSED CONTRACTORS DECLARATI
rEr W I hereby affirm that I am licensed unde rovlshons of Chapter 9 ISSUANCE DATE
4 (commencing with Section 7000)of Division 3 of the Business and ` BLO [ELECT. PLG. MECH.
F m z Professions Code and my license is in full force an fact. \ ❑ ❑ ❑
License ClassNumber L
4 z r w Datc fis' Contractor LQetyny
P,
rs .a BUILDING.PERMIT
¢ ¢ 4 OWNER-BUILDER DECLARATION
o au INFORMATION
is g w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL LL o j Law for the following reason(Sec.703 L5,Nosiness and Professions PERMIT ISSUANCE 70.00 U VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
¢ in ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. f 1 LIC.NQ r �-` ELEC. / '
a w m u rcyuires the applicant for such permit io file a signed statement that TOTAL {O PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
F Z rt
Law(Chapter 9(commencingwith Section 70001of Division 3 ofthe
i D Business and Professions Code)or that Ile is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F o the basis]or the alleged exemption.Any violation Uf Section 703 1.5
STOR vPE CONSTR.
aim byany,appueam for a permit subjects the applicant toacMI penalty ALT R-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
-❑ I,as owner of the property,or my employees with wlge.as ' PACK F LOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the structure Is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044,' usinan
ess d Professions
Code:The Contractor's License Law doesm apply to an owner of DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
property who builds or improves lhereon,$nd who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such imf?ose- / (Z
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA ) 200
builder will have the burden of proving that h - . . .
e did not build or im- BUILDING USE
prove for purpose of sole.). RE IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
❑ as owner of the property,Rin exclusively contracting with El11 ❑ 11
licensedcontractors In construct
the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. '
and Professions Code:The who
bildContractor's License Law docs not apply
to tr owner of property who builds tr improves rased u and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts Nonsuch projects with a comractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/70.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEAT RW/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK 17RS'UOMPENSATION DFCLARATION WATER TREATING EQUIP, 5.00
I hereby.v Rion that I have e cartificale of consent to sell-i nsu D'' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.).
Policy No. Cnnhponyu}�;.a
0. ❑ ifed copy is bvnv,�,'tarnished RE SPRINK ENERGY T 24
Z 2 em -d m IF ith c'Y inspection division.
O Apvlicant i MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
~ w PERMIT ISSUANCE 10.00
2 - CERTIPICA I'li OpEXEMPT ION FROM WORKERS b t. FLOOD ZONE A.L.U.C.
L COAL PF:NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Lel
d- o (This section need not be completed if the permit is for one d TOTAL Y❑ IN Y ❑ IN
Z Innulned dollars($100)or less.)
U O 1 certify that in the peflut n in,n of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner so as no
O w become subject to the Workers'Cooipensat ion Laws of California.
a Date Applicant BUILDING /fZ
} W NOTICE TO APPLIC\N'I': If,alter makingirMs Certificate of Ex- ALTER OR ADD TO MECH. 5.00 Nv
F ? 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 I0=CF.Ivt) 4.00
CONSTRUCTION LENDING AGENCY AIR HAN LING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm thin (here is a Construction lending agency for EXHAUS HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Gv.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that'I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county BOILER-COMP(3 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 (Over 100,000 BTU)SEE FEE SCH. MECHANICAL (�-T1
above-mentioned property for inspection purposes.
(We) agree to save, cmnif and keep harmless the City of MISC.- REFER TO.ORD.
Cupertino against fin f s,j d hen is, costs and expenses which y CONST.TAX
..hay n h Awa P�a ohs said City in consequence of the PERMIT ISSTANCE 10.00 0
gra i of tlMECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
TOTAL /0G (�
hrazor ate I
INSPECTOR COPY