09712 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 'G 1 1
ADOREss / r I�Ut� BUILDING-ELECTRICAL-PLUMBING -MECHANICAL OJ
OwNER'S f0 PLAN CHECK VALIDATION
i NAME VQTY. ELECTRIC PERMIT FEE
PHONE f//- A)
rUNT CTORs UTLETS-SWITCHES-RECEP 10.00/1.00 /Y�L.T/
N p+e , I uc.Nc:� LIGHTING FIXTURES 10.00/1.00 3
coNTRAcroR's
ADDRESS ILI PPLIANCES-RESIDENTIAL 4.00
I "
PHON PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3,00
ARC ®OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
ASS MOTORS SEE FEE SCH. ,/(\
w
SERVICE CHANGE 20.00
O
Zo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 0 5
TW ISSUANCE DATE
u I hereby affirm that I am licensed under provisions of Chapter 9
y < N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H Z Professions Cot,anJ nI license is in full for'c and •fleet. I-I
Z o :A License lass Lie.Number' Z 1J
o Z r
Date - - Contractor T
a x f -JIP-1-Un"FUIL19L, BUILDING PERMIT
ac a:w a OWNER-BUILDER DECLARATION
u INFORMATION
o A MISC.- REFER TO ORD
w g w I hereby affirm that I ocas I exempt from the Contractor's License
VALUATION 5/FT.
H LL6p J Code:Law Any citylowing Glywh(Sec.7ires a permit to cOer nucLProfessions PERMIT ISSUANCE 10.00
Cade:Any city or county which requirese permit toconstruct,alter,
QQ Q p improve,demolish.or repair any structure,prior t0 It51s511anCe,aISO ELEC.CONTR. LIC.NO. ELEC.
y I, requires the applicant Wf such permit to file a signed statement(bat TOTAL PERMIT TO
w m LL he is licensed pursuant to the provisions of the Contractor's License L7�
Hzi
Law(Chapter 9(commcrenig with Section 7000)of Division 3 n fine f.'
a Business and Professions Code)or that he is exemfr
pt thereom and QTY. PLUMBING PERMIT FEE
W r o the basis for the alleged exemption.Any violation of Sectiun 703L5 STORIES TYPE CONSTR.
n ;m by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).)! ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages As BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will Jo 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[its own employees. eovided thatsuch
amprooe-
ments re intended or redfor
sale.
If, oevGAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA ) 200 BUILDING USE
builder will have the burden of proving that h - . - . .
e did not build or im- RES IND CON PB Other
prove for purpose of sal,.). INDUSTRIAL WASTE INTER. - 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of IIIc property, am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business 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
contracts for such projects with a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COM PI:NSA1ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have u.certificate of conwot to s,Ifhiinuri. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or u certified
Co
py thereof ISec.3800,•Lab.C.�).(�
I'olicY N'oS�.JOI_ )ompun`Y:R7l n'tc l ra-r.a tl
CetliOed.cDpy ls,herCby ffVPA''�shed. FIRE SPRINK ENERGY T 24
z Z 4 Certifi d copy'ii filed with the city inspection division. MISC.- REFER TO ORD.
p Applicant t - Y❑ IN Y ❑ IN
Cc: N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPISNSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not be completed if the permit is for One TOTAL Y❑ N❑ Y C] NE]
hundred dollars(8100)car less.I
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California. ^
a DatcApplicantBUILDING
} W NOTICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 4
F 2 emption,you should become subject to the Workeri 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 10=C,F.M.) 4.00
CONST'RUCI'ION LI!NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is u construction finding agency for EXHAUST HOOD(WITH DUCT) 5.00
I 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 64
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above -:P VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and stale.laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
I • hereby authorize representatives of this city to enter upon the
above-mentioned properly for Inspection purposesBOILER-COMP(Over 100,000 BTU18EE FEE SCH. MECHANICAL ]
. V
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ago' st Ubililies,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
if at ay ay accrue against said City in Consequence of the
gr
LOTofis permit MECH.CONT. LIC.NO. MECH.
TOTAL A3 Uy TOTAL
Signnfure�6 p' ant/ o Clor Date
INSPECTOR COPY ,
s. .
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