8366 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILDIND APPLICATION & PERMIT
SO WINK Q
O /O S G3�tinC Ave RESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8366
I OWNER'S
NAME T PLAN CHECK VALIDATION
a-WtG �- GI�J�tS 9oj(sr-g/V Ory• ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10:00/1.00 S
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRA TORS _rAPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENO.
aooREss SPECIAL CIRCUIT PERMIT VALIDATION
5.00 i---
ZIP EMP.METER OR POLE IN `°�°� 20.00
APPLICANT'S
ADDRESS MOTOSEE FE
2S0C.6H
SERC0. d�
Alp
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woo LICENSED CONTRACTORS DECLARATION TEMP.POLE .a X0.00 'S
¢z W I hereby affirm that I am licensed under provisions of Chapter 9eF ISSUANCE DATE
Z, A (commencing with Section 1000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w i Professions Code,and in license is in full farce and effect. ❑ ❑ ❑ ❑
zo i w o License Class Lit.Number •-
w Date Contractor _
¢ ¢ w
OWNER-BUILDER DECLARATION BUILDING PERMIT
X;a- I- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REF R TO ORD INFORMATION
so u O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.
L- - PERMIT ISSUANCE
w Code:Any city or county which requiresa permit to construct,alter,
D improve,demolish,or repair any structure,prior t0 its issuance,also ELEG,CONTR. LIC.NO.
ELEC. s G S
i , m LL requires the applicant for such permit to Cite a signed statement that TOTAL PERMIT TO
a he is licensed pursuant to the provisions of the Contractor's License
F z Q Law(Chapter 9(commencingwith Section 7000)of Division 3 of the ELf T �[ yai d�
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /V'4•�
¢ r the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
A. by any applicant fora permit subjectsthe licant toacivil penalty ALTER-DRAIN -WATER (EA.) 5,00
of not more than five hundred dollars($
$500).
O I,as owner of Inc property,or myy amp employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will
Code eJ or offered for sale (S the work,and the structure is not
(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's License Law does not apply m an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.00 5D,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 I NC.4 OUTLETS 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.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Otha,
❑ I,as owner of the property,an exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INCIfi'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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITAR 1 T' RM EA.400fK(10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
/ reason
f Owner Date WATER SYSTEM
C' .I 6.00 ACC.DATE ACC.FILE NO.
WO KF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to sel&insure,
or a certificate of Workers'Compensation Insurance,or a certified rZONINGENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPR INK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- Ole- REFER T0 ORD, v N1_ v ❑ N[D
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 4{}00 `p FLOOD ZONE A.L.u.C.
W COMPENSATION INSURANCEPLG.CONTR. LIC.NO. PLO.
Z (This section need not be completed if the permit is for one TOTAL 0 Y[3 No Y [] N[]hundred dollars($100)or less.
U O I certify that in the performance of the work for which this per. OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U rail is issued,I shall not employ any person in any manner so as to
become subject to the Worktam'Compensation Laws of California. _
i
Date.Applicant ALTER OR ADD TO MECH. 5.00 BUILDING -
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
U such provisions or this permit shalt be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=0C.F.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 the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO.100,000 B.T.U.) 8.00
Lender's Name �q
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is estI agree to comply with all city and county PLUMBING
ordinances and stateate l laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0000.T,U.) 6.00 Q
hereby authorize representatives of this city to enter upon the BOILER-COMP(Ove.100,000 BTU)SEE FEE SCM. MECHANICAL
above-mentioned property for representatives
of
purposes.
(We) agree to save, indemnify and keep harmless the City of 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
granting of this permit. MECH.CONT, LIC,NO, MECH.
TOTAL
Sig of licent/Contractor a e TOTAL 30 ,
OFFICE COPY