C 09700 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION • PERMIT NUMBER
t . ,LOG kitinIa APPLICATION & PERMIT
ADG5 ELECTRICAL—PLUMBING—MECHANICAL 09700,A OOcct —
Ilf 1 OWNER'S
NAME — PLAN CHECK VALIDATION
(�,� DTV. ELECTRIC PERMIT FEE
lel,. OY fe PHONE
NOMERAcr&broRslal UTLETS-SWITCHES-RECEP 10.00/1.00
(}
Cor,
uc.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
' AG�OrRE55 1/� 1'
I` ;s Q vHONE� IQ^l'I N PANELS 10'.00 In DATE OF APPLICATION
OR
RCHITEcr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
Sea1S d- uc.No -IS1 SIGNS TRANS. 3.00
ARCH.OR ENG. ALIOATION
AOOREEs SPECIALCIRCUIT 5.00 _
C P A V@ k CL AL1 I EMP.METER OR POLE INS. 20. �� tI ��®�
ADORE Nrs MOTORS SEE FEE SCH. U
APPLICA
73 So-SCLra 1X1.�W SERVICECHANGE' 20.00 1lgrtino
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��CaD
Fi W 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and ES PLG MECH.
r m i Professions Cod nJ my license is in full fo ec
z o w License�1{'i�s��T Lic.Number
gDntc—ILL-I-$,_.Contraclor k?r('yY
F N F
Q y f J
¢ ¢ w OWNER-BUILDER DECLARATION - ,BUIL RMA ION
MISC.— - REFER TO ORD INFORMATION'
F
;u 1 hereby affirm Ilett I am exempt from the Contractor's License VALUATION
LL o Law for the follbwL reason.ch re uires a,permit
to construct,nd Professions 10.00 : /T
r - g PERMIT ISSUANCE IC/�Yf(/L]f
Code:Any city or roe my which requirese permit to uanahaq
¢ ¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
wD LL requires the applicant]or such permit to file a signed statement that TOTAL
$ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
rzi Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
E E o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE -
¢ s-$ the basis for the alleged exemption Any violation of Section malty STOR TYPE 00 TH.
dLoa; - by any applicant for permit subjects thecivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500t):
❑ I,as owner of the property,or my employees
employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.[NITS
their sole compensation,will(S the work,and the re is not
intended or offered for sale (Sec. 7044, Business anti
Professions ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner work
property who builds ar improves thereto,and who docs such work FIXTURES-PER TRAP S,OO SO. .FLOOR REq TOTALACREAGE
eD
himself or through his own employees,provided That such improve- r�
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-1 INC.4 OUTLETS 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 an. GAS-EA.SYSTEM-OVER 4(EA.) 2,00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE m INTER. 30.00 E I❑ ❑N PS❑ Other❑
❑ 1,as owner of the property,aexclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I 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 Contractor(.,)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00RqC NO. PARCEL NO.
❑ lam exempt under See ,B.&P.C.for this I WATER HEATERW/VENT 6.00
Owner
Owner DateWATER SYSTEM 5,00 qt DATE ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of amsem to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copt La L.0
Policy No.off5ec.38Co pany,).�)SF4 C7
O ❑ Certified ropy is hereby furnished.
Z Z NeCertif• op is led w ,• c y' Ilion division. FIRE SPRINK ENERGY T2
F O Applicant MISC.- REFER TO ORD, Y❑ N E] v ❑ N�
CC CERTIFICATE OF EXEMPTION FRU WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.U.C.
UJ COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.No. PLG.
1 O (This section need not be completed if the permit is for one TOTAL V[J NEI V [ NE]
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY'
LL I- mit is issued,1 shall not employ any person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
y Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of 1?x-
? emplion,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 be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 �)
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE rD�
I hereby affirm that there is a construction lending agency for I EXHAUST HOOD(WITH DUCT) 5.00
the Performmm 1'the warKF�1.�p_r which this permit is issued(Sec. MICROFILM /
3097,Civ.C.), iQ a +--iitn -- HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nam
Lender's nAdre1104 HEATING UNIT(OVER 100,000B.T.U.)9.50
' ELECTRIC
I certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 4,00
40 information n correct. 1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to comply
with l city and c, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00
herebhereby authorize representatives ec this city to enter upon the abovees BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL 31
y
authorize
ned property forinsp of
tion putty to
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
rant' of this per - MECH.CONT. LIC.NO. MECH.
c q 10 K TOTAL TOTAL t Gf
igna collicant Contractor Date
OFFICE COPY