9500 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
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ADRILDESSN APPLICATION & PERMIT ����
c
�s iN DY BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
CONTRAC
• eTT 3 °NE? -U?6
NAME "
UTLETS-SWITCHES-RECEP 10.00/1.00
\7 J�3 0® %N LOC.NO V,0-' j LIGHTING FIXTURES 10.00/1.00
CONAIRESOTors PPLIANCES-RESIDENTIAL 4.00
TO TRA f
/' ,GHOrvE ) S� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCAEOR n ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rFEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS v"
4 /✓0' SERVICECHANGE 20.00 `
° 2 TEMP.POLE 30.00 1 6�0
Foo LI C NTRACTORS DG LARAT ION
a u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
h <n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N z Professions Code,and my 'cense is in full fore�' effect. El ❑ ❑
i'o w - License Class Lia Number
z OPE-P,
° Uate Coniair Tmaor -
a Y / Z BUILDING PERMIT
Ife ol OWNER-BUILDER DECLARATION
as a ° INFORMATION
X
; y I hereby all'irnl that I an,exempt Irom lire Contractor's License MISC.- REFER TO ORD
Heap J Law for the following reason,(See.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION 8/FT. 1
� w0 Code:Any city orcuunly which requires a permit to construct,alter,
Q Q ¢° Improve,demolish,or repair any structure,prOr tO its issuance,also ELEC.CONTE. LIC.NO. ELEC. lL+
°LL requires the applicant far such permit 10 file a signed statement that TOTAL
A w m U. he is licensed pursuant to Die provisions of the Contractor's License PERMIT TO
H z r Law(Chapler 9(<ommencing with Section 7000)of Division3ofthc -
a Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
et H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
a ; w by any applieuntfor a permit subjects the applicant lea civil penalty ALTER-DRAIN -WATER (EA.) 5.00
,,four mora than five hundred dollars($500).):
❑ I,as owner 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.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such innpmve-
mentsarenot intended or offered for sale.If,however.the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or int_ GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with El F-1 El El Ellicensed contactors to construct the project(Sec. 7044,Nosiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL 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 _ \ w J
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft \
the Contract.,',License Law. /10,00 TRACT NO. PARCEL.NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
rcuson
Owner Date WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO.
WORK Ii RS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00 -
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Worked Compensation Imm�nce,or a certified `e ZONING ENG.SITE N0.
copy thereof tSec.380o,Lab-C ,.. /
Policy ere Company ;,'.r • j
O ❑ Cert Opy is hereby fur is ed. FIRE SPRINK ENERGY T-24 A
r Z Z and copy is Cited wfill the city inspection division.
0 APp icant - MI .- REFER TO ORD. v N❑ v ❑ ,N�
CC w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
- LU > COAIPE:NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL 'Y❑ N❑ Y'❑ IN
Z hundreq��yL dollars IS 100)or less.)
U O I ce7illy-tllateip,}ye performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issueJ, I-sli"'all not employ any person in any manner so as to
O w becme subject to the Workers'Compensation Laws ofCaliforma.
e
} m NOTICE TO APPLICANT. If,after making this Certificate d Ex.a DatApplicant BUILDING ALTER OR ADD TO MECH. 5.00 I
F Z eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions Of the Labor CUEh, YOU must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS"rRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE v/ZI
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
lire performance of tire work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NarHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Addr Address ELECTRIC
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 slate laws relating to building construction, and BOILER-OOMP(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.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnnents, costs and expenses which PERMIT ISSUANCE - 10.00 CONST.TAX
nmy in any way accrue against said City in consequence of the
grant g his penniL / MECH.CONT. LIC.NO. MECH.
St
'6 S TOTAL TOTAL
y reef pplii Date
INSPECTOR COPY