7035 , APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES-,USE BALL POINT-PEN ONLY
BILI LDI NG PROJECT I DENT[
FICATION
• PCP�ER
M1/cITJNUMBER
APPLICATION & PERMITaDILDING
ADDRESS
10601 �4� /k'6' Cjpt BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
7035 G
G PLAN CHEC KVALIDATION
DTV_. ,`NAMEnsPrY .YSL( 3
15lELECTRIC PERMIT
PHONE FEE' 37
•
CONTRACTORS
NAME ung /n IeSo�` '�r?O�5•r ,��G UTLETS-SWITCHES-RECEP 5.00/1.00
/TIw!/G•F-+�" uc.No. LIGHTING FIXTURES 5.00/1.00
DDRESS gsn2
ons
ADDRESS
APPLIANCES'-RESIDENTIAL 4.00
wM'.
PHONE rl QO PANELS 5.00 NATE APPLICATION
ORRCHITECT,.♦ w ' SIGNS 6.00 ENGINEERPLAN CHECKK FEE ?.C.NO.
'ry �✓)�'Y S -
uc.NO. - SIGNSTRANS. t - 3.00
ARCH.OR ENG. - PERMIT VALIDATION
AODAYSUSPECIALCIRCUIT 5.00
.335 utp�E.. wh'I; s.Tas 112
ZIP TERAP.METER OR POLE INS. 15.00
i
APPLICANT MOTORS SEE FEE SCH.
ADDRESS -- �(/��,/Ol
/f'S �� SERVICECHANGE - 10.00 - //J S
woo LICENSED CONTRACTORS DECLARATION /
a o w I hereby affiRn that 1 am.licensed under provisions of Chapter 9 PAID ISSUANCE DATE
y (commencing with Section 7000)of Division 3 of the Businessand
4 y BLDG. ELECT- PLG. MECH.
r
D.z Professions Code,and my license is in full force and effect. I r It �rr--1��'yss f�
z 0 m- License Clan Lic.Number - �. _ U H r)�.L I, I.IF J ❑
0 y r,��./(' Dale a/1 a -Contractor `�
am 7 ��' �- - BUILDING PERMI, 7....�.
w u „ 'OWNER-BUILDER DECLARATION . (,1} j`Jpl NATION
e'xl g LL I hereby affirm that 1 am exempt from the Contractor's License MISC.- _ REFER TO ORD
a_ a, Law for the following mason. 7031,5,Business and Professions PERMIT.ISSUANCE - VALUATION SIFT.
Code:Anybityorcounly which requiresa permit to construct,alter, 6'00
a,¢7O improve,demolish,or repair any stmetu r.prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC. / v V
0 ir requires the applicant for such permit to file a signed statement that ' TOTAL PERMIT T
a w m he is licensed pursuant to the provisions of the Contractor's License
rzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �NTis,Q,�jyL frs/�Qtre-
Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
IS I_o the basis for the alleged exemption.An
T g p the
nt tSection malty STORIES TYPE CONSTR.
o;- by any applicant for a.permit subjects the applicant lDacivil penalty ALTER-DRAIN -VENT-WATER (EA.14.00
of not more than five hundred dollars($500).):
❑, 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP 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,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work 2, FIXTURES-PER TRAP. 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsare not intended orofferedfor sale.IL however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00 _
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of proving that h .
e did not build or im- .REB IND CON PB Omer
prove 1,as owfor er ofsale.). - INDUSTRIALWASTE INTER. 20.00 •❑ ❑
❑ d as owner of the property,he exclusively.7044,tBu with
licensed contractors ID construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to owner of property who builds improves thereon,and who LAWN SPOINKLERS-OVER 5(EA.) 1.00
contracts for such Projects with a contrlracmAs)licensed pursuant m
Contt
the Contractor's License Law.. SEWER-SANITARY-STORM EA.200ft/5.00 -TRACT NO. PARCEL No.
❑ tum exempt under Sec ,B.&P.C.for this •' WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 -
_ I hereby affirm that I have a certificate ofconscnt to self-insure, ZONING ENG.SITE NO.
or a certificate of.Workers'Compensation Insurance,or a certified
/ copy thereof(Sec.3800,Lab C..
1'nlicy No. Company pd2_
O O Certified copy is hereby tomis cd{GZ: B¢-Z J FIRE SPRINK ENERGY T44
Z Z( ❑ Certif/yF opy Is fie wiD th cily inspection division.
Applicantll MISC.- REFER TO ORD. ' y ry� yEl ryo
-0:/N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C.'
Wa COMPENSATION INSURANCE . PLG.CONTR. LIC.NO. PLG. / „ter ❑ ❑ ❑ N❑
EL O (This section need not be completed if the permit is for one TOTAL V N V
:D Z hundred dollars IS 100)or les.) -
U O ' 1 certify that in the performance of the work for which this per, OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING fCJQ
a ALTER OR ADD TO MECH. 4.00
} m NOTICE you
APPLICANT: If,after making this rs'Certificate of Ex-
F ? eruption,you should become subject to the Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code, you meat forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(T0 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000CFM.) 5.00 SEISMICFEE
I herebyaffirmthat there is'a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.P.50
Lender's'Name " ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county BOILER-COMP13 H.P,or 100,000 B.T.U.1 4.00 PLUMBING �'
ordinances and slate laws relating to.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 properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERM IT ISSUANCE - 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting hi permit _ MECH.CONT. s LIC.NO, TOTAL Q�
IrL26- 4 TOTAL
Signal r o pp cant)Conlrac ate '
OFFICECOPY