10049 APPLICANT TO FILL,IN'INFORMATION WITHIN RED LINES - LISE<BA_ LL POINT PENONLY
BUILDING PROJECT IDENTIFICATION- ' PERMIT NUMBER, . 1,
BUILDING APPLICATION & PERMIT, A l/�)
ADDREQSS 10,049
10(y 9
1R - BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ' , I V
OWNEW`S', yUp •--13(�- - !?LAN CHECK VALIDATION .
NAME :'' V QTY. ELECTRIC PERMIT. -
`?l?YEhIE,i PRorvE, \ C{'� 3• '
CONTRACTOR'S UTLETSv-SWITCHES-RECEP 10.00/1.00 ^ //��
NAME ., r P7 1 D ..
VK1!•\L �Lliy \j\ ` uc.rvo. LIGHTI NG.FIXTURES .10.00/1.00 .
CONTRACTORS 3Z9 r\�k�ST - APPLIANCES-RESIDENTIAL -.4.00 '
ADDRESS 4\,- - PR..16 d� -
�., PHONE ,e PANELS 10.00 - DATE KATION
ARCwTECi PANELS IDV ER 200'AMP) 20.00 CANCHE/-CK FEE ' P.C.NO.
DR - lir II urFri I IIVLI
ENGINEER - - `
7 LIC.NO. SIGNSTRANS. 3.00
ARCH.OR ENG. r PERMIT VAt-IDAT'ON
ADDRESS �" SPECIAL CIRCUIT 5.00 1�,..p/��/^}-•
TEMP.METER OR POLE INS.
ADDRESS - 20 00
'APPLICANT'S .3�q �` � S..Y- MOTORS SEE FEE SCH. - - - -
� '-
y ISERVICE CHANGE 20.00 F • , ��'
o'o LICENSED CONTRACTORS DEC LARATION TEMP.POLE - 30.00 w
4 U u I hereby affirm that 1 am licensed under provisions of Chapter 9 " ISSUANCE DATE
N G i (commencing'with Section 7000) f Division 3 of the Business and ,BLDG. ELECT. PLG MECH.
Z F w i Professions 50 •pan yycense is in full for-,
D m - Lice •C us LIL Numb 1 -' - ❑ ❑ ❑
9 r w Datc Coiltr mr C O M P U T
a Y s - BUILDING PERMIT'
¢ o.n� � � OWNER-BUILDER DECLARATION - . } INFORMATION
E:
I hereby affirm that I am exempt from'the Contractor's License MISC. R F TO ORD '
Le VALUATION $/F,T...
FUO4. Law for the following reason.(Sec.7031.5,Business and Professions - PERMIT 00 ,
Code'Any city or county which requires a permit to construct,alter, -
in
K Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CO NTR. - LIG NO.
ELEC.
Er a myuires the applicant for such Permit to file a signed statement[hal TOTAL PERMIT TOLa '
A.
m he is licensed pursuant-to,the provisions of the Contractor's License - -
za' Law(Chapter 9.(commencingwith Section 7000)of DivGkm3 afthe - - -
g 4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE'
H the basis for the alleged exemption..Any violation of Section 7031.5 "s -'. ... • _ ' . I STORIES TYPE CONSTR._
by any applicant Erna permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 -
of not more than five hundred dollars(8500).).
❑ 1,as owner of the properly,or my employees with wages as
their sole compensation,will do the work,and the structure is not - BACK F LOW PROTECT.DEVICE 4.00 OCC:GROUP 'RES.UNITS
intended or dfferch 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
propertywhobuilds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
.• himself or through his own employees.Provided that such improve-
ments urenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is-sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA:)' 2.00
builder will have,the burden of proving that he did not build or ire- BUILDING USE
prove for purpose of sale.). - - I NDUSTR I A L WASTE,I NTE R. 30.00 RES IND CON PB Other
❑ 1,as owner of the propeity,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.S. 6.00 . ASSESSORS PARCEL NO.
and Professions Code:The Contractor'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 -
conlraclsforsuchprojectswithacontractons)licensed pursuant to SEWER-SANITARY-STORM EA'.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL N0.
❑ 1 um exempt under Sec. ,B.&I'.C.1'o,this WATER HEATER W/VENT 6.00 -
reason
Owner .Dat DaWATER SYSTEM- 5.00
.. ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, -or u Certificate of Workers'Compensation Insurance,or a certified ZONING Y ENG.SITENO.
copy Ther S •s3800,L ab.C.� -- ``
Policy N2 Sompany '\Vd
❑ Certified copy is hereby furnished - FIRE SPRINK ENERGY T-24
Z Z CerlilIg� o y is Qed with the ty inspection division.
O Applicant cAa�il- \wynj�.\t•.� C.- MISC.- REFER TO ORD. -'Y ❑- N❑ Y ❑ N❑
Fy PERMIT ISSUANCE _ 10.00IFFE FLOOD ZONE .A.L.uc.
K
CERTIFICATE COM E EXEMPT[ FROM WORKERS' '
W COMPENSATION INSURANCE PLG.CON LIC.NO. PLG.
d O (This section need not be Completed if the permit is for one - \"ATOTAL \ �Q V❑ NE] Y.❑ N❑
hundred d011ms(5100)or less.)
U O 1 certify that in the performance of.the work for which1his per- 'QTY . MECHANICAL PERMIT . - FEE ' - '-FEE SUMMARY
mit is issued,I shall1not employ any person in any manner so as to -
Ow become subject to tine Workers'Compensation.Laws of California, BUILDING
a Date -Applicant ALTER OR ADD TO MECH. '5.00 t'
} rn -NOTICE TO'APPLICANT: If,after making'thls Certificate of Ex _
emption,you should become subject to the Markers Compensation APPLIANCE _ 5.00 PLAN CHECK
provisions of the Libi Code, you must form
thwith'coply 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 UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency far EXHAUST HOOD (WITH DUCT) - -5.00 -
the performance of the work for which this permit is issued(Sac. MICROFILM
3097,Civ CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Noun
ddr HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's AAddress ELECTRIC '
Icertify that lhave read this application and sine that the above VENTILATION FAN (SINGLE) 4.00
information u correct-1 agree to comply with all city,and county PLUMBING
BOILER H:P.Or 100,0006.T.U.I 6.00
ordinances and state laws relating In building construction, and
'-� hereby authorize representatives,of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. - MECHANICAL '
above-mentioned property for inspection purposes. '
(We) agree to save, indemnify and keep'hurmless the City of MI_S_C.- _ _ 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
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL f
\ 'TOTAL:
:.!•
Signature of App mat/Contractor Date - -
x
OFFICE COPY