9506 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT . 95 6
ADDRESS
ILDING -ELECTRICAL-PLUMBING-MECHANICAL
Ow ,eV 141 NE q PLAN CHECK VALIDATION
NAME g'�3-� ELECTRIC PERMIT FEE
//I UI NE
CONTRACTORS
NAME
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
C• J ��� LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
A DDn ESS
PHONE PANELS 10.00 DATE OF APPLICATION
i ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP( 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
noo ARCH.EOR ENG,
r _ SPECIAL CIRCUIT 5"0Q PERMIT VALIDATION
Z, EMP. METER OR POLE INS. 20.00
noo ss TS MOTORS SEE FEE SCH.9AAJ
4 hie, SERVICE CHANGE 20.00 -" /
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 j //d `
c o U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
t- z (commencing with Section 7000)of Division 3 of the Business and
y Q n w
H m i Professions CoJu,a.,fit.,fitmy license is in full Hire,an,]cll'eel. BLD ELECT. PLG. MECH.
I, 0 O m - License Class-Lic.Number
° ve - O Date Contract.!
P m a -a I BUILDING PERMIT
¢
OF a OWNER-BUILDER DECLARATION
iL o a u MISC.- REFER TO ORD INFORMATION
X ;LL y I hereby affirm that I am exempt from the Contractor's License
u0st Law for the following reason.(See.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
� - Code:Any city orcounty which requires a permit to construct,alter, /' ,(���
te N 2 improve,demolish,or Repair an structure.prior t0 its issuance,also ELEC.CONTR. LIC.NO. r�o f/ V
¢ ¢ ¢O �� P P' Y ELEC. /
n
DLL requires the applicant for such permit to file a signed statement that TOTAL PERM T TO
w m m he is licensed pursuant to the provisions of the Contractor's License
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
s i D
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 "' STORIES PE CONSTR.
s3by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not..or flim five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00
their sole conmensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 ai
Code:The Contractor's License Law does not imply to an owner of i
• 'property who builds Or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided That such impolve-
ments are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-1 1 NO.4 OUTLETS 6.00
or improvement is sold within one year of completion,Ota owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES INC WN PB Omer
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00
/ p I,as owner of[lie property,am exclusively contracting with O^'
tic Tsed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS CEL N0.
' and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Rtcreon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
/ the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iunl e' opt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason_Q
Owncr_Q�_ .- �.;r�}-e-j,Tte WATER SYSTEM 5.00
�.�2 gi �•��r��' ACC.DATE ACC.FILE NO.
WOR 'Co PE A1TON );C.l.nenTlo WATER TREATING EQUIP. 5.00
'I hereby uR n shut 1 have a can satioc ufcunsmd to self-in
Or Ii cert ifica[c Workers'Compensation Insurance,Or a car If d ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Cerlit ied Copy Is hereby furnished. FIRE SPRINK ENERGY T"24
z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. YE] N Y ❑ N[:]
~ rn PERMIT ISSUANCE 10.00
•-�W - ]FICATE OF FLOOD ZONE A.L.u.c.
1kr W 7 COd not beTcoN(NSU if the PLG.CONTR. LIC.NO. PLG. Y EJ NE] Y E] NE]
9, Z hundred
section Mrs reed not be complete) if the permit is for one TOTAL
I rt! ent dollars(5100)pe lesfort
�LL O I certify that h the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,je I shall not employ any person in any manner so as to
U become Object to the Workels'Compensutiom Laws of Calilirznia.
O a Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING E�
>- rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(- Z enlptiun,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions Of ilia Labor Code, you nmst forthwith comply with FEE
U such provisions or this permit shall be decried revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE a 6W
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 0
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
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l 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 authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL -w
above-mentioned property for inspection purposes.
(We) agree save, indemnify and keep harmless the City of MISC.- REFER TO,ORD.
Cupertino a 1st liabili tics, ' rents, costs and expenses which CONST.TAX
It, way accrue a• In said City in co/necquc ce 01 tile - PERMIT ISSUANCE 10.00
1grfillmg [his PerntiL / R -CH.CONT. LIC.NO. MECH.
u, fe V °T"` TOTAL �S
'\ 'ApWR/ ctor are
INSPECTOR COPY