12002 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12002
ADDRESS
8 rent venue BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER's PLAN CHECK VALIDATION
NAME
Mr, John Cotte PHONE OTY• ELECTRIC PERMIT FEE
NAMERAcroR's UTLETS-SWITCHES•RECEP 10.00/1.00
Atals Heating LIC,NO.465266 LIGHTING FIXTURES 10.00/1.00
ADDREssrORa - PPLIANCES-RESIDENTIAL 4.00
155 Commercial St.HONE 739-0516 PANELS 10,00 DATE OF APPLICATION
ARCHITECT
ORPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC NO.
OO
ENGINEER
Lie.NO. SIGNS TRANS. 3.00
OR
ADDRESS END' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANT'S /1 p
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 UJ3�
woo LICENSED CONTRACTORS DECLARATION
at u I hereby affirm that 1 am licensed under provisions of Chapter 9
2 w ISSUANCE DATE
al a.
(commencing C with Section 70se)i In Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H - Professions Code n4�py license is in full f of(Acl 1:1 ❑ ❑
o i D Licens a Zl1-Lic.NumberA.� OSSo
yr H w Date O Contractor
at y
M Ix Ix ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
w- D a U INFORMATION
R. w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w O er Lew for the following reason.(Seo 7031.5,Business and Professions VALUATION $/FT.
- w PERMIT ISSUANCE 10.00
re wtf Code:Anycityor countywhich structurepermittoconsuanNalter,
S 2 at D improve,demolish,or repair any sUUCtgtt,prior 10 its issuance,also ELEC.DDNTR, LIC.NO. ELEC.
n wD 2 requires the applicant for such permit to file a signed statement that TOTAL
$m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i 4 G Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
a 1- r� the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.-
n3 � by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
.' property who builds or improves thereon,and who does net,work FIXTURES-PER TRAP 5,00 aQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedorofferedforsule.If,however,the building 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- IGAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 VB6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B.
In an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 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 ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofcousent to self-insure,
or a certificaf,t(e$Foqf Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy PGIictNo�o, Gl l'f'Ddhitj' Allied Pacific
O C�yCertified copy is hereby furnished. FIRE SPRINK ENERGY T-ZO
Z Z H( Certifi��ladd��fcPaPY is led h the city inspection division.
O Applicant XL1a3 I�ea �ng MISC.- REFER TO ORD. Y NY El N[J
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU a COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
(This section need not be completed if the Permit is for one TOTAL v N Y 0 No
:0Z hundred dollars(SI00)Orless.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERM4T- FEE FEE SUMMARY
LL F mil 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.
d
Date-Applicant BUILDINGant ALTER OR ADD TO MECH. 5.00
>_ DO NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE rte;._ 7, 6- 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F,M) ,4. p
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER11 F.Ivt:)�No SEISMIC FEE
1 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 HEATI NG UN IT ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address -
• 1 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 cdnnty gO1LER•COMP PLUMBING
ordinances and state laws relating to building construction, and (3H.P.cr100,000B.T.U.) 6.00 p-
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over ,000 BTU)SEE FEE SCH. MECHANICAL /O d�
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC. EF R TO ORD.
Cupertino against liabilities,judgments, costs and exgpenses which PERMIT-ISSUANCE 10:00 �Q� CONST.TAX
in in an wa accrue against said Ci[ in corse uehe. of the
gr ingot this perm) MECH,CONT, LIC.NO. MECH.
Q a � s TOTAL
TOTAL
ignature of Applica Contractor a1 '/"'���6 100.0 0
OFFICE COPY