09525 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
AENc APPLICATION & PERMIT-
ADDRESS
I Ess M
l . BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 0 9 525
O PLAN CHECK VALIDATION
NAME L.Ifs' QTY. ELECTRIC PERMIT FEE
`' PHON
NRAMEAcro s OUTLETS-SWITCHES-RECEP 10.00/1.00
/
C.No. S LIGHTING FIXTURES 10.00/1.00
CONTRAS on's - PP LI ANC ES-RESIDENTIAL 4.00
ADDRESS
PNONF _ PANELS 10.00 DATE OF APPLICATION
ARCPTTM1 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PG.NO.
OR
ENGINEER
' uc.No. SIGNS TRANS. 3.00 All
ARCH.ESS ENG. SPECIALCIRCUIT 5.00 FERMI TION
ZIP TEMP.METER OR POLE INS. 20.00 ASG
ADDRESSTB MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 .C�ty 01
COPertl
TEMP.POLE 30.00
00 LICENSED CONTRACTORS DECLARATION �/Q -
a U U I hereby a(I ire that I an licensed under provisions of Chapter 9 ISSUANCE DATE
r z a, (conn encmg with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG MECH.
Fi Professions Cod d my license is in full lore nd a fegt_ ❑ ❑ ❑
zo - License Clas Li"No (Jf(�_
0 0 w Date CuNactor
a s BUILDING PERMIT
Ix Q
Ca OWNER-BUILDER DECLARATION INFORMATION
oA
ED MISC.- REFER TO ORD
X
3 LL N I hereby affirm that 1 am exempt from the Comractor's License VALUATION S/FT.
HNOJ Lawforthe following reason.(Sec.7031.5,Business and Pro@scions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
2 ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also. ELEC.CONTR. LIC.NO. ELEC.
- O m requires the applicant for such permit to file u signed statement that TOTAL E TO
X $w he is licensed pursuant to the provisions of Ile Contractor's License
Law(Chapter 9(ecmmencinywitln Section 7000)ofDtvaion 3 of the
a Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
tT-a the basis for the alleged exemption.Any violation of Section 7031.5 STOR S T E CONSTR.
i ; 5 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not marc than five hundred dollars(55000.):
❑ 1,as owner of the property,or myemployees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and tine structure is not
intended or offered for sole (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contactor',License Law does not apply to an owner of
property who builds Or improves thereon,and who does Such work FIXTURES-PER TRAP 5.ODLicyQ SQ FT.FLOOR AREA TOTAL ACREAGE
himselforof ugh intended
ownemployees,for sale.
If,h ever,the
improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00 DO
mems are not intended or offered for sale.If,however,the building
or im r will av is e h within o one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the hunlen of proving the he Aid no[huilA or inn- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with I El 11 13licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 V ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 �
tine Contractor s License Law. (QU TRACT NO. PARCEL NO.
❑ I:on excmptundcr Sec. ,B.&P.Cfin His SE TER HEATER W/VENT 6.00 VV
reason
Owner Date WATER SYSTEM 5A0 O0 ACC.DATE ACC.FILE NO.
WORKERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby infirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy di,n of(See 3800,Lah.CA
Policy No, Company
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z qfj�.CertifreJ opy is fled with the city inspection division.
0 A ICz...t L•`_._ �j MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Fy -f`*IT PERMIT ISSUANCE 10.00 OU FLOGO ZONE A.L.U.C.
� CIikTIFIGOMOFSATION ION FROM WORKERS'
W COMPENSATION but e ON INSU it the ,i PLG.CONTR. LIC.NO. PLG. Do Y❑ N❑ Y ❑ N❑
CL O (This dollars need not be completed if the permit is lin one TOTAL
� Z hundred dollars IS 100)or lass.)
0 O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. I. mit is issued,1 shall not employ any person in any manner so as to
0U become subject to the Workers Compensation Laws ofCalifornia. BUILDING
d Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT'. If, Her making this Ccrtificatemllix-
F Z_ emption,you should becon.a 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 UNITIOVER 10p00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfonnonce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
NHEATING 00,00
UNIT(OVER 10 B.T.U.)9.50
Lender's Name 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 state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 6.00
hereby auth0riec representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to Save, mccnmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran i o{this permit. MECH.CONT. LIC.NO. MECH.
1��gurefy, L�1'YS
TOTAL TOTAL
Signature o p Ica t)�ontaul Du[e
INSPECTOR COPY
I