7167APR,ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P
BUILDINGPROJECTIDENTI FI
BDILOING OPLICATION & P AIL�SS T ,
• j/ ADDRESS /\/��,
/\ ZZZ%3' _J'�+�C ST" BUILIO.��ING- ELECTRICAL- PLUMBING -::aaMECHANICAL
MM.Hs -,IR Iti' N. 9"Y 4 .a: a4 i Nlz i"e
LIC. No. 3 (v 15E 1
ARCHITECT 1,
OR
ENGINEER
r - _ LIC. NO.
r
21P
APPLICANT'S
ADDRESS
o¢i
r o o_, EICENSEU CONTRACTORS DECLARATION
S,
I hereby affirm that Ian licensed under provisions ofChapter9
y < Hmennng with Section 7000) of Division 3 o! the Business and
r ❑ a m sslmll Code,' Amy Ilcemse iso full fore •' nd efle,
a i �•o L:acnse (8''lass_ _ Lie. Number (p.1 .'2•� I '
r La Contractor�yyyx111y' Ol�'
Q y E J
¢ ¢ w.< OWNER -BUILDER DECLARATION
w;' N I hereby affirm That I am exempt from the Contractor's License
r u o J Law for the following reason. (Sec. 7031.5, Nosiness and Pro@scions
Coda: Any city or County which requires a permit to construct, alter,
¢ ¢ o improve, demolish, or repair any structure, prior to its issuance, also
ne w m 1 requires use applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
'r z Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i i 04 Business and Professions Code) or that he is exempt therefrom and
¢ I- o the basis for the alleged exemption. Any viola tion'of Section 7031.5
a 3 m by any applicant fora permit subjects the applicant to acivil penalty
of not more than five hundred dollars ( 8500).):
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code:.The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such Improve-
ments an not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or im-
prove Cor purpose of smleJ.
❑ I, as owner of the property, am exclusively conlracling with
licensed contractors to construct the project (Sec. 7044, Business
�I n lProlessions Code The Contractor's License Law does not apply
to an owner of property who builds or improves (hereon: and who
' • contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
❑ 1 am exempt under Sec. , B.&P.C, for this
reason
Owner Date
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
% ' copy thereof lSec. 3gCo parry 1.
/RJJ`//") Policy No Company
❑ Certified copy is hereby I' niched.
z Z -
el
-•d y is de wI h h ci inspect division.
F O :A Iplicam _
y C17RIIFICATE OF EXEMPTION FROM WORKERS'
W 2tr COMPI:NSATION INSURANCE
t1 0 1'I'his Section need not be completed if the permit is for one
Z hundred dollars ($IOD) or less)
V O 1 certify that In the performance of the work for which thus per -
LL I- mu Is Issued, I shall not employ any person in any manner sic its to
U become subject to the Workers' Compensation Laws of California.
UJ Date Applicant
} 2 NOTICI i'TO APPL ICANP: 11, after making this Certificate of Ex -
F _ enlption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith, comply with
V such provisions or this permit shall be deemed revoked._
CONSTRUCTION LENDING AGENCY ,
1 hereby affirm that there is a -construction It,
agency for
the pml'... mace
of the work for which this permit Is issued (Sec.
3097, Civ.CJ.
Lender's Name
Lender's Address "
I certify that I have read this applicatioA and. state that the above
information is correct. 1'agree to comply will] all city and county
ordinances and.state laws relating to building construction, and
hereby autlrori7o representatives of'this city To enter upon the
above-mentioned property for inspection purposes.
(We) agree to save; indemnify and' keep harmless the City of
Cupertino against` liabilities, judgmeryrySS�1 costs and expenses which
may III, any wgy acgQh :l ARVO in oonseauence of thr
Lure
-SWITCHES-RECEP
5.00/1.00
!'FIXTURES
5.00/1.00
:ES - RESIDENTIAL
4.00
A. L. U.C.
Y ❑ N ❑
5.00
'TOTAL
8.00
ANS.
' 3.00
;IRCUIT
5.00
TER OR POLE INS.
15.00
• I. SEE FEE SCH.
CHANGE ' .
10.00
MISC. - REFER TO ORD I , I
ALTER -DRAIN & VENT -WATER (EA.) 4.00
BACK FLOW PROTECT. DEVICE 2.00
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
FIXTURES -PER TRAP 4,00.
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4,00
GAS - EA. SYSTEM' -.OVER 4 IEA.) 11.00.
INDUSTRIAL WASTE INTER. - 2000
LAWN SPR W KLERS: 1 INC 5 V.B., 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/8.00 .
Y
PERMIT NUMBER
7167
PLAN CHECK VALIDATION
PAIL)
WATER HEATER W/VENT 4.00
WATER SYSTEM 4.00 -Acl
WATER TREATING EQUIP. 4.00 i
Z(
❑I❑Io
ILDIN ERMIT
NFORMATION
1ATIOI
ON $/FT.
4/V .
PERMIT TO
ES TYPE CONTR.
�V
OUPRES.UNITS
t
IF AREA. TOTAL ACREAGE
BUILDING USE
ID CON PB On.,
7.. ❑ ❑ ❑
ES50RS PARCEL NO.
10., - PARCEL NO.
TE ACC. FILE NO.
" ENG. SITE NO.
'
FIRE SPR INK
Y❑' N❑
ENERGY T 24
Y❑ N❑
MISC:- REFER TO ORD. .,,'�
PERMIT ISSUANCE 0.00
FLOOD ZONE
Y ❑ N ❑
A. L. U.C.
Y ❑ N ❑
ONTR. LIC. NO.
'TOTAL
ra L
r' { IT �� ''
�O xMECHANIC/1L'rVERMIT'� . a�FtEE
i § FEE SUMMARY
� .,, y,.,f
,•,
BUILDING
ALTER OR ADD TO MECH.' 4.001
APPLIANCE ' '41.00
PLAN CHECK '
FEE -
AIR HANDLING UNIT (TO 10=C.F.M.) r` 3.00
AIR HANDLING UNIT (OVER 10400C.F.M.)' 5.00
SEISMIC FEE
EXHAUST HOOD WITH DUCT) - 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U)" '4.00
HEATING UNIT(OVER 100,000B.T.U.P.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
PLUMBING '
BOILER-CDMP(3H.P.Or100,000B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. • REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE3.00
CONT.' LIQ NO:
MECH
TOTAL
x
TOTAL O�yJ /v1f r'
OFFICECOPY