11065 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING XPI. APPLICATION & PERMIT
aooREss 0 11065-MECHANICAL ooBUILDING-ELECTRICAL-PLUMBING
OWNER'S • PLAN CHECK VALIDATION
N OTY.''e ELECTRIC PERMIT FEE
Pen Q�PA40[ PRONE -n
'CONTRACTORS OUTLETS-SWITCHES'-RECEP ]0.00/1.00
A E
-. InIT Lc.rvo. LIGHTING FIXTURES 10.00/1.00
SNTRACTOR'S '7O 1 APPLIANCES-RESIDENTIAL 4.00
A SS JQ
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITEC PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ARCH.OR ENa., - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION .
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
Arvr's MOTORS SEE FEE SCH.
ADDRESS �f
' SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
F i U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w i Professions Cod nd n, V''rose is in full f. ❑ ❑ ❑
p i m W 1 0 1 s Lia Numb
Dale Contractor
a u f BUILOING'.PERMIT
¢ tc w¢ OWNIi R-BUILDER DCCLARA'fION INFORMATION
o A U MISC.- REFER TO ORD
N I hereby affirm that I am exempt from the Contractor's License
u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
Cade:Any city or colmty which requires a permit to constrt¢I,alwr, t��
BE
Q Q 0 'improve,demolish,or repair any structure,prior 10 Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
BE
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
P-za Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe �^
f 4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT .- _ FEED
BE the basis for the alleged exemption.Any violation of Seclion7031.5 - STORIES TYPE CONSTR.
by any applicantf.r.�pernsit subjects the applicant loucivil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,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 not
intended or offered for sal.-(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 theraon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
Puntsare not intended orofferedfor sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 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.r im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND COONN PB .roar
❑ 1;as owner of the property,am exclusively contracting with ❑ ❑ _ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC S V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Commctor'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(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
D lam exempt under Sec.-,BAIP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKRRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that 1 have a certificate ofconsent to self-insure, ZONING ENG,SITE NO.
or a cerlificale of Workers'Compensalion Insurance,or a certified
copy 1h 'f
Policy NeIf�A6�-l_23lafr -
C] ❑ CefiillieQ copy is hereb furnished. FIRESPRINK ENERGY T 24
�f]�Certi�edt,ppQ file c' inspection division.
_Z 2 p� va MISC.- REFER TO ORD.
D plicae[_ Y❑ N❑ Y ❑ N❑
~� r�2 CERTIFICATE OF I IFROM WORKERS'
PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COWIPENSATION INSURANCE
PLG.CONTE. LIC.NO. PLC.
Q. a ('Phis section need not be completed if tiro permit is for one OTAL Y❑ N Y ❑ N(D
:) Z hundred dollars IS 100).1 less.) -
U O 1 certify tial in the performance of the work for which this per- QTY. - MECHANICAL PERMI„T, n FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to , " 1 If`•v
U
w become subject to the Workers'Compensalion Laws of California.
Date-Applicant - BUILDING
a ALTER 0R ADD TO CH. 5.00
} N NOTICE TO APPLICANT: If,aftersubject
making this Certificate sa lix-
F Z emvision you should become subject to the Workers'Compensation APPLIANCE CQQE PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. Alfl HANDLING UNIT ITO C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that 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. A
HETING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.L 2
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that,I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ror4inances and state laws minting to building construction, and BOILER-CDMP(3H.P.Dr100,0008.T.U.) 6.00
Aremby authorize representatives of this city to enter upon the BOILER-COMP lover 100.00.BTUI SEE FEOLCH. MECHANICAL �/�
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC. EFER 0 ORD.
Cupertino against liabilities,judgments, costs and exjmnses which PERM ISSUANC 10001UM
CONST.TAX
may in any way accrue against said City in consequence of the
I .(this rail MEOH.CONT. LIC.NO. ECH.
1 11 NC-x�T►nUTOTAL/?
TOTAL
lure ofApplicant/ContractUPM
OFFICE COPY - -I