09709 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING to-r APPLICATION & PERMIT
ppys BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09709
OWNER PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
_ v onE
CON 1 HACTOR'S
N EOUTLETS-SWITCHES-RECEP 10.00/1.00
E kI x LR.N aZ LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ONAC RRAcraR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00 C t S-J{
"HON O PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PE,r�2elc C1QA�il£L�- PANELS (OVER 200 AMP) 20.00
N
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENGPERMIT VALIDATION
ADDRESS IFOce S4y!'ne14: SPECIALCIRCUIT 5.00
ZIP frEMP.METER OR POLE INS. 20.00
AESMOTORS SEE FEE SCH.
S
ADDRDDRESS
SERVICE CHANGE 20.00
wo 2 1 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U U I hereby affirm Ilial I at,,licensed under provisions of Chapter 9 ISSUANCE DATE
w z O1 (commencing with Section 7000)of Division 3 of the Business and a a B BLDG. ELECT. PLG. MECH.
F o i Professions C de,a and ny license is in full fn �F n ct.
Z o m - Licensc las - Lia.Numbcr [.�_ Zq , - ❑ ❑ ❑
o m F w Dutc Contractor .
A� 'tel•
¢ ¢ a OWNIi R-d UILUER DECLARATION BUILDING PERMIT
a 3 a u INFORMATION
w g LL H 1 hereby affirm that 1 an,exempt from the Contractor's Licensc MISC.- REFER TO ORD
LOV Law for the following mason. 7031.5,Business and Professions pERM1T ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county whichrmluiresa permit to construct,alter,
W ¢ improve,demolish,or repair any structure,prior to its issuance,also FLED.CONTR, LIC.NO. ELEC.
ca
d wF O a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License M
H z ¢
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhc
i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Anv violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora pernil subjects the applicant to a civil penalty 'ALTER-DRAIN -WATER (EA.) 5.00
of nut more than five hundred dollars(S500).):
❑ 1,as owner of time property,or my employees with wages as BACK F LOW PROTECT:DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the aructum is not
intended or offered for role (Sec. 7044, Nosiness and Professions DRAINS-FLOOR,ROOF,AR EA,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 F IXTUR ES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
mentsfre Through his ownemployees,provided that such improve
me rdsare not intended his
oroffered ernploets,sale.provided
that suhebuirove GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner, GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or no-
provaforpurposeofsalcJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Orn
❑ I,as owner of the 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 Codc:The Contractor's Licensc 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 contmctons)Ifecowd pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'CO,NPF-NSA TION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby nlNrm that I have a certificate of consent to sell'-infurq ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified ,
copy Cher ISec.3800, ,00y); _ �.
Policy N ,ampamY JiN
( N S
O Ce"fN copy
"hereby urnished FIRE SPRINK ENERGY T 24
Z Z U Certifig d opy iS fild with the city' inspection division.
O Applh,tnt;'1L11I991gw1 E L MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
LUN CER'I'IFICA'FF OF EXEMPHON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
IL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Q ('Phis section need not be completed it the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars CS 100)of Icss.)
V O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
kL F- mit is issued,1 shall not employ any person in any IDan.,,ao as to
Ow become subject to the Workers'Compensat ion Laws of California. BUILDING
y Dam nppl"°t;t ALTER OR ADD TO MECH. 5.00
} to NOTICE TO AITLICANT: IL,aNer making this Certificate of Es-
F- Z 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 lic deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm thud there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 'U+
the performance of time work for which this permit is issued(See MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and stato that the above VENTILATION FAN (SINGLE) 4.00
information is cancel. 1 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 arthoriee representatives of this city W enter upon the BOILER-COMP (owrl00,DDDBTU)SEEFEESCH !/)J
abuve-mentioned property for inspection purposes. . MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which /d v CONST.TAX
may in any way ace[ a against said City in consequence of the PERMIT ISSUANCE 10.00
granum g'o his per MECH.CONT. LIC.N0. MECH.
TOTAL a /b TOTAL
S I pp¢ant/Contractor 10.11C
INSPECTOR COPY