11966 APPLICANT TO FILL IN'INFORMATION WITHIN'RED LINES --USE BALL POINT PEN ONLY
` BUILDING PROJECT I DENTIFICATION PERMITNUMBER
BUILDING _ APPLICATION & PERMIT
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
11966
OWNER's �' .... PLAN CHECK VALIDATION
"AME _ ELECTRIC PERMIT FEE s
O.) ONE l
CONTRACTORS OUTLETS-SWITCHES-RECEP 10,00/1.00 v!-
y NAMy c_ x
"\ I �'SY7 sec.NO. I DbS� 1 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
ADDRESS , ;
vRENE IIJf� PANELS 10.00 U J DATE OF APPLICATION
ARCHITE TPANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO, SIGNS TRANS, 3.00
ARCHEOR ENG. SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS �' EE FEE SCH.
'
SERVICE CHANGE ' ;' ` 20.00
wO o T
LICENSED CONTRACT DECLARATION 4 1 l
<u U 1 hereby affirm that I am licensed Under provisions of Chapter 9 �n ISSUANCE DATE
G2 w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. 'MECH.
m o Professions Code andlny license is in full fore nd fife '
'i
0.0 - License Class VV Liu,Numher 9 - ❑ ❑-
o m H wJ Dale /O-I6 C.,Gmetor
m f d r - ✓ BUILDING PERMIT
OWNER-BUILDER DECLARATION
X 3 d Hs" I hereby offinn that I am exempt from the Contractor's License MISC. R O ORD INFORMATION
v.. VALUATION SIFT.
FLLoa Law for.the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
IED Code:Any city orcounty which requireSa permit to construct,alteq
Q d� Improve,demolish,Or repair any Structure,prior to its Issuance,also ELEG.CONTR. t LIC.NO. ELEC. M
ec w 10 requires the applicant for such permit to file a signed statement that TOTALV •' - ipERMIT TO
he is licensed pursuant to the provisions of the Contractor's License _
I- !i
Law(Chapter 9(commencing with Section 7000)of Division 3 of[he
y o Business and Professions Code)or that he is exempt therefrom and DTV. 'PLUMBING PERMIT FEE 7
¢ i a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
-a by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
• ,l their sole compensation,will do the work,and the structure is not DCO.GROUP RES.UNITS
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 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 6.00
marls are not intended Or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
r prove.for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB "Oma,
❑ 1,as owner of the property,'am cZelusively,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 Lew does not apply
to an owner of property who builds or improves thereon,and.who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
'contracts for such projects with a contrucloOa)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. ' TRACT NO. PARCEL NO.
❑' I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
s 'ACGOATE ACG FILE NO
ry WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. ,. 5.00
1 hereby affirm.that I have a certificate of conwrt to self-irsore, + ZONING
or a certificate of Workers'Compensation Insumncu,or u certified- ENG.SITE N0.
copy there fp y_Sec�80QLab.CJ. St- �n�
Policy ere 0,L.b. - l4 1,
O ❑ Certified copy is hereby'furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certi(ie y-rs filed 'ih the city ec n division.
• �Qo� A+ diHt MISC.- REFER TO ORD:
J` Applicant T319_ flan Y❑ N❑ V ❑- N
y CF,RTI FICATB OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLooD zoNE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTE. LIC.NO. . - PLG. - -
� Cl (This section need not be completed if the perm it'is for Hire 'r TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars(SHOO)or less.)
U O 1 certify that in the performarice of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner so as to
0W become subject to the Worker Compensation Laws of California. BUILDING
Q. Date Applicant - ALTER OR ADD TO MECH. "5.00
• } to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,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 he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10MC.EM.) 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. - MICROFILM
3097,Cie.CJ. t - HEATING UNIT(TO 100,000 B.T.U.) 8:00
Lender's Name EG UNIT(OV ER00TU
10 , 00 B.T.U.)
. 0
Lender's Address HATIN
- ELECTRIC
1 certify that I have read Hits upplication and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER'-COMP(3 H.P.0(100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP love,l00,000BTU)SEE FEE SCR. MECHANICAL
(Wa agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
- --.- Cupertino ago' et liabilities,judgments, costs and expenses which CONST.TAX
may in any y accrue gainst said City in consequence of the PERMIT ISSUANCE 10.00
gr .g.fthl permi MECH.CONT. LIC.NO. MECH.
/ TOTAL - 'TOTAL -
ignatureo Applican n tar Date O
OFFICE COPY