09897 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
OR55 �V
�� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL u`�'
-97
OWNER'S PLAN CHECK VALIDATION
NAMECITY. ELECTRIC PERMIT FEE
�. {// PHONE
CONTWACTOR
NAME ` `/ OUTLETS-SWITCHES-RECEP 10.00/1.00
GA. /J sec.No. :13 60 LIGHTING FIXTURES 10.00/1.00
DDRESS oR's
APPLIANCES-RESIDENTIAL 4.00
YI? ? 14Ze PHONE //V/// PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NOp
OR PANELS (OVER 200 AMP) 20.00 yi
ENGINEER LIC.NO. SIGNS TRANS. 3.00 t 1
oDRESS °' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDDDRESSRESS
SERVICE CHANGE 20.00
0 0 0LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a is. I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG.
so M
o v, I'm fastons Cod� nd t I'censo is in full fmqr,e� d a ee. ❑ ❑ ❑
Z z vi W License Class a' �y� Lic.Number "TS
9 Uam 6 Contructor ^'+'4 /ti'
¢ m E BUILDING PERMIT
¢ w ¢ OWN Ii R-Ii UI LEER DECLARATION
A 0 a " MISC.- REFER TO ORD INFORMATION
se 3 s- I- I hereby affirm that I unt exempt from the Contractor's License VALUATION SIFT.
F
u. LL
Law for the following reason.(Sec.7031.5,Business l'rofessigns PERMIT ISSUANCE 10.00
so Code:Any cityor county which requiresapermit to construct,alley,
Q Q Q 0 Improve,demolish.Or repair any structure,prior t0 Its Issuance',also ELEC.CONTR. LIC,NO. ELEC.
u w m¢ requires the applicant for such permit to file a signed statement that TOTAL RMIT TO
be is licensed pursuant to the provisions of the Contractor's License
i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Proesfsions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT `FEE /
ES r the basis for the alleged exemption.Any violation of Section 7031.5 STORI 'TYPE CONSTR.
u ; $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).1:
❑ 1,asowner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the 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.FLUOR AREA TOTALACREAGE
• himself or through his own employees.Provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA ) 200
builder will have the burden of proving that he did not build or im- . . .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Other
❑ I,as owner of the property',am exclusively contracting with Ela❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code: I'he Contractor's License Law does nal apply
In an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lamexemptunder Sea .B.&P.C.for thio WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'CONI PENSATION DECLARATION WATER TREATING EQUIP. 5.00
T(' 1 hereby affirm that I have a certificate ofconsem to self-insure
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).z���/r-� gN0-
Poli y N.. Conspary C
Gatified copy is hereby famished FIRE SPRINK ENERGY T.24
Certficd c Ii1cJ wit I ')y •d ion division.
MISC.- REFER TO ORD.
ZO Applicant Y ❑ N❑ Y ❑ N❑
cc W .:RTIFICA'I'I..OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU IsCOMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v❑ N❑
-a Z( This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)Or IcW.)
U O 1 certify that in rhe performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued I shall not employ any person in any manner so as to
U become subject to lire Worker Compensation Laws of California.
lyatc Applicant BUILDING
a pp j ALTER OR ADD TO MECH. 5.00
In NO'I'ICF 'TO APPLICANT': If,alter making this Certificate of Fx-
F-. ? cmption,you should become subject to the Workers'Contpansation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lonliwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 rhe work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100.000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agrtt to comply with all city and county .. PLUMBING
ordinances send state laws relating to building consvuctinn, anJ I::Q BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorim
representatives of this city W cn ter upon the BOILER-COMP Inver 100,000 BTU)SEE FEE SEE, MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless rhe City'of MISC.- REFER TO ORD.
Cupertino against liabilities•judgments, costs and expenses which PERMIT ISSUANCE 10.00 �D CONST.TAX
accrue may in any way against said City in consequence of the
granting of this per L MECH.CONT. LIC.NO. MECH.
/a TDTA / TOTAL
ignature of Applicant/Contractor Dare /
INSPECTOR COPY
V Ii