10269 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES -,USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
aUIIDING APPLICATION & PERMIT
AIR BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
10269
o rvER' - • . k, PLAN CHECK VALIDATION '
NAME - O m, " - ELECTRICS PERMIT v ' FEE,'
PNONE [ ..
� crvE acTGRs OUTLETS-SWITCHES-RECEP 10.00/1.00
c.NG. LIGHTING FIXTU RES 10.00/1.00
r.an EaCTOR's rjss� APPLIANCES-RESIDENTIAL 4.00
AGGRESS '7
PHONF PANELS 10.00 .DATE OF APPLICATION
OORcmTECT PANE LS 'OV
ER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. SI GNS TRANS. 3.00
ADDRESS arae. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
nv TEMP.METER OR POLE INS. 20.00
APPLICANT'S - Y
ADDRESS MOTORS SEE FEE SOH. ✓y/�� /
SERVICE CHANGE 20.00
woo LICFNSED CONTRACTORS DECLARATION TEMP.POLE 30.00
aw AI
u 1 hereby afR[it that I am licensed uncle[Division 3 of the of Chapter 9 168U NCE GATE
wD w Prommions C with Section 700e i of fulfr3 of the Business and BLDG. ELECT. PLO. MECH.
i Professions Code,and rrty license is in full force and effect ❑ ❑ ❑
2 O y - License C ssq��=+L�Lic.Number
4 F a Data ��G/�L Contractor
1- N
wa OWNER-BUILDER DECLARATION i ,.BUILDING PERMIT' `fib
MISC.- REFER TO ORD p - INFORM AT,ION A+R
w ;LL y I hereby affirm that 1 am exempt from the Contractor's License - -
.. o¢ Law for the following reason.(Sec.7031.5,business and Professions VALUATION $/FT.
H - g PERMIT ISSUANCE 10.00
Code:Any demyshof counpairty anyich structures ap riorttownsuanc ,alsotruct,after, -
¢ ¢ ¢ improve,demolish,or repair any structure,prionto its issuance,also ELEC.CONTR. LIC:NO. ELEC.
u S °¢ requires the applicant for such permit to file a signed statement that - TOTAL
w m he is licensed pursuant to the provisions of the Contractor'.q License PER/MIT TO
Hzi
Law(Chapter 9(commencing with Section 7000)o'Divlslon 3 of the
i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT ', - :,FEE l"l IT
¢ I- m the basis for the alleged exemption.Any violation of Section 7031.5 '_- ` _ -STORIES ,TYPE CONSTR.
a3 - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
0 L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4,00 OCC.GROUP 'RES.UNITS
their sole compensation,will do the work,and the structure is mol
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00 '
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves th Creon,and who does Such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that Such improve-
mentsarenotlntendedorofferedforsale,ILhowevegthebuilding - GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 `
builder will have the burden of proving that he did not build or im- BUILDING USE
,prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 - RES IND CON -P9 Omer
O 1,as owner of the property,am exclusively contracting with, -
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dots not apply _
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See. - ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
1 hereby affirm that 1 have a certificate of consent to self-insure, _
or a certificate of Workers'Compensation InsuruRce,or a ce tified ZONING _ENG.SITE NO.
copy theryt�,0($L5bf00;..1� 110,1 Dom^ , _„ , /�,t C
Policy a �Lf-Corr(earr§ l �.CfM..L.F-ll.�ft
" � ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z 'Ged copy is filed with the city-inspection division.
FO pylic yc MISC.- REFER TO ORD. v � N❑ ERG 24
,� W ERTIFICATE OF 13XIiMPT10N FROM11 WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Il.l 0 (This Section need note be.compateINSURANCE if lite permit is for one PLG.CONTR. LIC NO. TOTAL - V N� Y N�
ao
::) Z hundred dollars IS 100)or less.)
LL O 1 certify That in the performance of the work for nthis per- CITY. MECHANICAL PERMIT- FEE; ;FEE SUNIMARV. p
F mit is issued,I shall not employ any person in any manner so as to
0
W become subject to the Workers'Compensation Laws of California.' - -
y
>_ NOT Applicant BUILDING
W NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH.- 5.00
Z eruption,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 IQWOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm.thut there is a construction lending agency for EXHAUST_HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00K 00
Lender's Name _
Lender's Address H EATING UN IT(OVER 100,00 B.T.U.)9. 0 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLO .00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOIL ER-COMP(3W.P.or 1 .O .00
v hereby authorize representatives of this city to enter upon'the BOILER-COMP ver T 1 E CH. MECHANICAL 2
above-mentioned property forinspection purposes.
0110 agree to Save, indemnify and keep harmless the City of MI - REFER TO ORD.
Cupertino against liabilities,judgmentsosts and expenses which P SUANCE 10.00 UC CONST.TAX
may in.any way accrue against sal ity in consequence of the
gran as of this permit MECH.CON . LIC.NO. MECN.
�� pq �7�9/ TOTAL dy TOTAL -
atureof pplicant/Contractor Date ji Z /7
" OFFIC COPY