11067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - -- PERMITNUMBER r
BUILDING APPLICATION & PERMIT
ADDRESS
- S � BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 11067
/ OWNER'S 14
f ,s,,� . g' 4 a „ PLAN CHECK VALIDATION
OTFEE,
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'� PHONE
CONTRACTORS
UOUTLE
ETS-SWITCHES-RECEP 10,00/100
fMe "e T k_7 uc.No. LIGHTING FIXTURES, 10.00/1.00
romrRAcroR's JOv
n 1 PPLIANCES-RESIDENTIAL 4.00 :
A E55 1 1
PHON PANELS 10,00 DATE OF APPLICATION
ORRCHITEr LIC.NO.
200 AMP) 20.00 - PLAN CHECK FEE P.C.NO.
' ENGINEER - ,c.No. SIGNS TRANS. 3.00 � '
ARCHDDRESS END $pEGIAL CIRCUIT - 5,00 PERMIT VALIDATION
ZIP - EMP.METER OWPOLE INS. 20.00
ADDRESS MOTORS: SEE FEE SCH. (�` 7fi —
• ` .
ADDRESS � •.
SERVICE CHANGE - 20.00 q/;
o0,2 - I ( 1
F-o o '�� LICENSED CONTRACTORS DECLARATION '
ri u I hereby affirm that I am licensed under provisions of Chapter 9 .ISSUANCE GATE
¢ a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Co nd ren i se is in full 1' '
_z o m — Lice Cla — Lic.Num e - ❑' Id I
o z — Date C.mGmto `-C
P m r:. BOILDING PERMIT'
ac o n O OWNER-BUILDER DECLARATION - y+,jNF,OfiMATION'ds+”
w3: y' 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
'Fuo J Law for the following reason.(Sec.7031.5,Businessamd ProfessionspERMIT ISSUANCE - 10.00 VALUATION $/FT..-
� w> Code:Any city or county which requires a permit to construct,alter,
00 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
— D a requires the applicant for such permit to file a signed statement that TOTAL ,/y/{�$P EjR,M[I T(,7J0
` ' w he is licensed pursuant n ing provisions of the )of
License
tz¢
Law, Professions with
Section 7000)of Dwlslon3ofthe K { -
E m o Business and Professions Code)or that he is exempt themfrom and QTV. r Jx ,'Rr PLUMBING PERMIT a 'moi 1 FEE
a H m ,the basis for the alleged exemption.Any violation of Section 7031.5 " h " ' ` ti f 't x STORIES TYPE CONSTR.
aby any applicant for a permit subjects the applicant ton civilpvadlty ALTER-DRAIN&VENT-WATER (EA.) 5.00
oC not more than five lmdr
ned dollars($500h.):
❑ I,as owner the property,or my employees wRb wages as BACK FLOW PROTECT. DEVICE. 4.00 OCC.GROUP RES.UNITS
their sale compensation,
ion,will the work,and the structure is not
intended or offered for sale (Sec. 7044;Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES.-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare-not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA) 2.00
builder will have the burden of proving that he did not hu - . - .
ild or am- BUILDING USE
prove for purpose of sale.). .. - RES IND CON PH Other
ClI,.as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. '6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractoos),licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. B.&P.C.for this reason WATER HEATER W/VENT 6.00
El
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, -
or a certificate of Worke'rrs''�Comp- Salton Innsuura eMor a cer bled ZONING ENG.SITE NO.
Polcy N f �PwWw {� �f 1Y -
Q ❑/ Certified copy is hereby furnished
Z Z pk, CergO c a GI ty FIRE$PEINK ENERGY T 24
F 0 'Applica� Inspectimi dlvisioa nt TO ORD. Y❑ N❑ Y ❑ N❑
LUCE RTI F I CATE Op E X F-MPTION F-ROM WO R K E RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LOIC.
W COMPENSATION INSURANCE - PLG.CONTE. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one _ TAL Y❑ N❑ V.❑ Is❑
1..1 0 hundred dollars($100)or less.)
1 certify that in the performance of the work for which this per QTY . a' MECHANIC $i,' 1 FEE. - FEE SUMMARY<
,LL F mit is issued,1 shall not employ any person in any manner so'as to 1
O W become subject to the Workers'Compensation Laws of California. a - M A0
IS, Date Applicant BUILDING -
} 0 NOTICE TO APPLICANT: If,after making this Certificate of E' ALTER OR`ADD TO MEC _ 5.00 -
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE �( PLAN CHECK
provisions of the Labor Code;you must forthwith comply with FEE
(') - such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 1 .M.)� 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000.F.M.),6.00 SEISMIC FEE
1 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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) B.00 ,
Lender's Name -
' Lender's Address HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) r 4.00 . -
information is correct. I agree to comply with all city and county BOILER-COMP(3'H.P.OL 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state'laws'relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (0veri100,000 BTU)SEE FEE SCH. MECHANICAL /
above-mentioned property for inspection purposes. -
(We) agree to save, indemnify and'keep harmless the City of MISC.- �- REF R TC/ORD. -
Cupertino against liabilities,judgments, costs and expenses which pERMIT SUANCE 10.00 CONST.TAX -
may in any way accrue against Said City In consequence.oC[ha
m I of Ihis permit /'� MECH.CONT. LIC.NO. MECH.
y1 , 1�II p 1 1 TOTAL ('�/�/1 TOTAL .�
ureof Applicant/ onlrac[or - ate U I~C•�1'fJ1�(' �((�LI�J "
OFFICE COPY