11021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
r- ^} BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ' 10 21
OWNER'S ` PLAN CHECK VALIDATION
NAME //- CITY. ELECTRIC PERMIT FEE'
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
LIc.ND LIGHTING FIXTURES 10.00/1.00
ADOR s
ADDRESS DRESS , APPLIANCES-RESIDENTIAL 4.00 `
-
PHONE992
PANELS 10.00 GATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
UC.NO. SIGNS TRANS. 3.00 '
ADDREOR SS ENG. SPECIAL CIRCUIT' 5,00 PERMIT VALIDATION
,P EMP.METER OR POLE INS. . 20.00
Ara
ADDRESS - MOTORS SEE FEE SCH.
DRESS E55 - ,
SERVICE CHANGE 20.00
.100 LIC17NSLD CONTRACTORS DECLARATION
< u OU I hereby'afl irm'that 1 am licensed under provisions of Chapter 9 - ISSUANCE DATE
z"' (commencing with Section 7000)of Division 3 of the Business and
,0< y BLDG. ELECT. PL❑G. MECH.
H N z Professions Cod alnd�mgqlicense is in full ffATA10N
0 O m - License C�,1s 1�Lic.Number
O r Dant Contractor_
a u E d - BUILDING PERMIT
o n u OWNER-BUILDER UECLA INFORMATION
se ; u_y I hereby affirm that 1 am exempt from the Contractor',License MISC.- REFER TO ORD
LL o e, law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
� - -' Code:Any city orcounty which requirtsa permit to construct,alter,
2 va Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
D u requires the applicant for such permit to file a signed statement that TOTAL p
A. m m he is licensed pursuant to the provisions of tire PERMIT TO
e Contractor's License - M _x(•1171
Hz ¢ Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe G
4 O Business and Professions Code)or that he is exempt tticrefrom and DTV. PLUMBING PERMIT FEE
H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a 3 by any applicant(or a permit subjects the applicant ton civil penalty
of not more than five hundred dollars($500j). - ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 - OCC.CROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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-
Trentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.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 or im= BUILDING USE
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 RES: IND CON PB Omer
❑ 1,as owner of tine property,am ex Clusivdy contracting with ❑ El 0 D ID
licensed contractors to construct the project(Sec. 7044,Businoss LAWN SPRINKLERS-1 INC 5 V.B. . 6.00 ASSESSORS PARCEL NO.
and Professions Code:'fire Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who, LAWN SPRINKLER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO,
rea0 nl um exempt under Sec. ,BAP. for this WATER HEATt" .,.�
0
6.0
Owner - Date WATER SYSTEM 5.00 ACC.DATE PCC.FILE NO.
WORK ERS'COMPENSAT10N DECLARATION WATER TREA-Cot RVNberfino 5.00
I hcklo,affirm that I have a certificate ofconsent to self-insure,. -or a certificate,of Workers'Compensation Insurance,qr a certified ZONING ENG.SITE NO.
Copy thet �({�S}yr} 00,Lah.CU L g ' , '
1'olicY N(!•X[01/�Compmny AkLu,> >
C) ❑ Certified 'opy is hereby fumrshed. " FIRE SPRINK ENERGY T 24
Z 2 Certdle op/' Lied wit! the cit in eCO.,,division.
•O _ A "ant L/ 1 MISC.-. REFER TO ORD. Y E] N 0 Y,❑ N[]
it CERT CAT Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE' 10.00 �.(7 FLOOD ZONE A1:U.C.
L COAIPF.NSATION INSURANCE PLG.CONTR. LIC.NO. PLC.
O.'Cl (This section need not be.completed if the permit is for one _ TOTAL Y E] N[] V [D N�
hundred dollam(S I DO)m IessJ
U O I certify that in'the performance of the work far which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
0'O become subject to the Workers'Compensation Laws of California:
Q. Dat', Applicant BUILDING
} 0 NOTICE TO APPLICANT: If,after making tliis Certificate of Ex- ALTER OR ADD TO,MECH. 5.00
�.... Z traction,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 10,000C.F.M.) 4.00 -
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GF.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 tiro work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). '- HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender'sNanre 4 HEATING UNIT 100,000 B.T.U:)9,50
Lender's Address ELECTRIC
I certify that l have re ad 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 ��{{
y� ordinances and state laws relating.to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T,U.) 6.00 i �V
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCR. MECHANICAL
above-mentioned property for inspection purposes. 'I
(We) gleeto save, indemnify and keep handless the City or 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
' mgofthis permit. // MECH.CONT. LIC.NO. MECH. _-
C (� TOTAL 1�;O
hi=reo pplcant/Contractor' . 4 Date TOTAL
OFFICE COPY