9130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
So LDING APPLICATION & PERMIT n O
ADDRESS N I `�
7.y.'J, 3S Bow1�6eR Su ITC D BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
.� OWNER'S tura OEtiIU CIL"( Q 1220. PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
NAMERACTORS ;) Ea BUIvO SYS`TF3ria5 UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. 46013'2.- LIGHTING FIXTURES 10.00/1.00
r-ONTRACTOR'S /pO57 IM eM4PC. prl4. APPLIANCES-RESIDENTIAL 4.00
ADDRESS O
GVpE'127rN0 PHONE 173-q Tell PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.NO, SIGNS TRANS. 3.00
ARCIA.OR ADDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v w (commencing with Section 7000)of Division 3 of the Business and I hereby affirm that I am licensed under provisions Of Chapter 9 r'CY '� IA. ISSUANCE DATE
a< BLDG. ELECT. I PLG. ME
F D'^ Professions Code nd my license is in full force 46$1¢S2. _ �1
License CIS Lim Number l 1y64 O El El
I/l I
Dale Nm
Coctar VJl I'E
Ic w u OWNER-BUILDER DECLARATION r BUILDING PERMIT
MISC. REFER TO ORD INFORMATION
1'xv ; u I hereby affirm that I am exempt from the Contractor's License VALUATION 5/FT.
u 0 j Law for the following reason.(Sec.7031.5,Business and Professions
- PERMIT ISSUANCE 10.00
ca 0 Code:Any city or coo my whiny structure,
prior
to construct alter
also
Q Q ¢rs improve,demolish,Or repair any Stlnetnre,pllu!tO IIS ISSnanCe,aISD ELEQ CONTR. LIC.NO. ELEC_
i E: G u requires the applicant for such permit to file a signed statement that ./ TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License
r z Law 9(commencing with Section 7000)o f Division 3 ofthe
_ a
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ��
i / P
(C 11- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ;-. by any applicant for a permit subjects the applicant boa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(SSOO).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4,00 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. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who Joes such work F IXTUR ES-PER TRAP SEE FT.FLOOR AREA TOTAL ACREAGE
•. himself or through his own employees.provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-
EA.SYSTEM-1 INC.4 OUTLETS 6.0
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 euaOING USE
builder will have the burden of proving that he did not build or inn- RES IND CON PR Omar
th
prove for purpose of e.). INDUSTRIAL WASTE INTER. 30.00 El El Q 1:1 Q
❑ I,as owner of tote property,am exclusively 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 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 conlmctol(a)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,BAP.C.for this
reason WATER HEATER W/VEN1.Air% 6:00
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING E 00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensalio Insurance,or a Certified
ollpy to m�yy( all, 601.1h uT t 0
Policy NoJO
Z ❑ Certified Py
1
coe b furnishe Y.I
Z- ❑ Certified co 1 d itl a i ipcetion division. FIRE SPRINK ENERGY T44
/ MISC. EFER TO ORD.
F O ApplicanLU t Y N Y [] NC]
CC to CERTIFICATE OF EXEMPTION PRO ORKERS' PERMIT ISSUANCE 1QB0 �� FLOOD ZONE A.L.U.C.
CL Q (This section need not beTcomple ed Rift eFpermit is for one PLG.CONTR. LIC.NO. TOTAL Q PLG V N Y❑ NC]
�) Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per, FEE SUMMARY
LL 1- mit is issuedI shall not employ any person in any manner so to
QTY. MECHANICAL PERMIT FEE
O w become subject
ct to the Werkers'Compensubion Laws Of California.s BUILDING
y NO Applicant ALTER OR ADD TO MECH. 5.00
} rn NOTICE TO APPLICANT: If,after making this Certificate sa F:x-
F ? esnplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 as PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10100DGF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER10,000 0
5.0SEISMICFEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 0
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000
Lender's Name HEATING UNIT(GYER 100, .19.50
Lender's Address ELECTRIC
I certify toil I have read Ihis application and state that the above VENTILATION FAN (SINGLE In U
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER-ODMP(3'H.P.Or 100,00 6.00
hereby authorize representatives of this city to enter upon (lie BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. �3
(We) agree to s e, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again a i'ties,judgments, Costs and expenses which PERMIT ISSUANCE 10.00 /0CONST.TAX
may in any y a e against sa'it ty in consequence of the r'
grantingof is P97. MECH.CONT. LIC.NO. MECH.
TOTAL �5-- TOTAL ��
Signatur Y pplicant/Contractor Da
OFFICE COPY