10079 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT
aVILVING
ADDRESS&C) B�An - 10079
ASE BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
Mptwl � ] ,11i[1 QTY. ELECTRIC PERMIT FEE
1 ' , 1 PHONE O�a-JJ `F'T'7
COONTERACTOR's UTLETS-SWITCHES-RECEP 10.00/1.00
A11 eA \Aeqri r-cs.C.`NO LIGHTING FIXTURES 10.00/1.00
I�Rn, 1� S. APPLIANCES-RESIDENTIAL 4.00
1 1 PHONE PANELS 10.00 DATE OF APPLICATION
ORRLHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
' uc.NO, SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
SS
zIv EMP.METER OR POLE INS. 20.00
AADD HESSPPLICANTS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
'09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
M4 i w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
w a c BL❑OG. ELECT. PLG. MECH.
H 7 i Professions Code Id m se is in full fo I
i D y - Lice la Lic.Num
vI 1-w Date Contracto
a sa s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATIO
'A o d v - - INFORMATION
w ; ¢y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H ` O< Co.forth,following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION E/FT.
:Fw Code:Any city orcounty which requires a permit to construct,alter,
¢ ¢¢O improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC,rv0. ELEC.
i Z D ¢ requires the applicant for such permit to file a signed sta l emend Ihat TOTAL PERMI
TTQ
w$ he is licensed pursuant to the provisions'of the Contractor's License
r t i Law(Chapter 9(eommencing with Section 7000)of Division 3 ofthe (l�
aD Business and Professions Code)pr that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
z
Ir
¢ I-m the basis for t..e alleged exemption.Any violation of Section 703malty STORIES TYPE CONSTR.
by any applicant fora permit subjectsthe$500).licalainncivil penalty ALTER-DRAIN VENT-WATER of not more Ikon five hundred dollars(5500).): -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business unit Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property.who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
-� 4ents are through his own employees,provided that such improve
,nlentsarenot intended oroffered emploees,sale,provided that such
emprovg GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
/ builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
• prove for purpose of sale.). RES IND CON PB Otbe,
❑ 1.as owner of the property,um exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ D ❑ ❑
licensed contractors Io construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects'with a contmctortS)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate Fconsent to self-insure, ZONING ENG.SITE N0.
cop
or a certiif�igcCatte$oof�Workers'
Compensation Insurance,or a certified
Polic y the
Ng0(J1SJ.'�L1A rf��
-
❑ Certifle copy is hereby fu nishcJ. FIRE SPRINK ENERGY T44
Z 2 ��Certik, is filed i ms action division:
FO Rjrpllcant \ COLA Iw1l.� MISC.- REFER TO ORD. Y � N❑ Y[3 No
rn PERMIT ISSUANCE 10.00
' � - CERTIFICATE OF :XEMPTIUN FROM WORKERS' FLOOD zorvE A.L.u.c.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z' (This section need not he completed if the permit is for one [:]TOTAL Y N� Y
hundred dollars IS 100)or less)
U O I certify that in the performance of the work for which tis hper- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
n Data � Applicant ALTER OR ADD TO MECH5.00 BUILDING
>. w NOTICE TO APPLICANT: If,after making this Certificate of Ex
I. ? emotion,you should become subject to the Workers'Compensation APPLIANCE . 5.00 PLAN CHECK
or visions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 706,,000 C.F.M. (,'4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IO VO C. .M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 1 8.00 ym
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
and
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 10 , ABT 1 SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- EFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which PERMIT SSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra i of this permit. MECH.CONT. LIC.NO. MECH.
URI I oTAL p aj TOTAL
I tore of Applicant/Contractor Detc
OFFIC OPY