18070 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
aaILOING - APPLICATION & PERMIT
ADDRESS I,
O YOV,� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL y, 1 8070
OWNE/R''S//-////y�//n� � 5
NamEV'' N�%VL K/ '!V - PLAN CHECK VALIDATION
ELECTRIC PERMIT FEE W
PN N
CONTRACTOR'S
NAm UTLETS•SWITCHES-RECEP 10.00/1.00 �, 7
LIGHTING FIXTURES 10.00/1.00
CO T ACTOR'S
APPLIANCES-RESIDENTIAL 4.00 -
✓7 PANELS 10.00 - DATE OF APPLICATION
OgCHITECT - 2 (/ ./ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER / -
- c.No. SIGNS TRANS. 3.00 .
ARCH.ORENO. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
iS, EMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
cr oo SERVICE CHANGE 20.00 Sg�Y 22 1993
wLICENSED CONTRACTORS DECLARATION y
Z w I hereby affirm that I am licensed under provisions of Chapter 9 :IT
- 5
m a (commencing with Section 7000)of Division 3 of the Business and
H y Z Professions Code,ed license is in full fore arq Leonddbl ' L PLG. MECH.
c i _ W License s Lic.Numbe,ca-IN 3 �J
F L H J Date Contractor 1 El El
a w ¢ OWNER-BUILDER DECLARATION .. BUILDING PERMIT
w ;LL N 1 hereby FiEFER TO ORD INFORMATION
al Drm that I um exempt from tiro Contractor's License
F LOj , Law for lire following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
Any city count which requires PERMIT ISSUANCE
Code:'An t county ( permit to construct,alter, 10.00
ac improve.0 G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires the applicant for such permit to file a signed statement that, TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
H z <
Law(chapter 9(commencing with Section 7000)of Division 3 of the
4 0 - Business and Professions Code)or that he is exempt therefrom and
M r $ the basis for the alleged exemption.Any violation of Section 7031.$ DTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollar,($500).):
❑ I,as owner of the properly,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 does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owncr-
builder will have the burden of proving that he did not build or am. GAS•EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00 - RES IND CON PB Other
0 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 A55ESSORS 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 it contruclods)licensed pursuant to
the Contraclnds License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ Ium exempt under Sec.' ,tl.&P.C.for this
on WATER HEATER W/VENT 6.00
owner - Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate ofconsent to self-insula,
or a certificate of Workers'Compensation Insurance,or u certified I ZONING' ENG.SITE NO.
copy thre
Polic
eof dry. � s'0 .
❑ Cetlllied copy is hereby famished FIRE SPRINK ENERGY T-14
Z Z 0 Certified cop Is f d,with t(e cit inspection division.
O APVlicant �, /V MISC.- REFER TO ORD. YE] N0 Y ❑ - N�
er to C 1 R1 117 OF li%li ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. pLG,
a. O (This section head not he completed if the permit is for one TOTAL Y❑ NC] Y❑ N[D
U ZO hundred dollars(SIOO)or less.)
1 certify that in the performance of the work for which this per. Q.�V MECHANICAL PERMIT FEE
LL F mit is issued,I shall not employ any person in any manner so as to FEE SUMMARY
O W become subject to the Workers'Compensation Laws of California.
d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Z NOTICE TO APPLICANT: If,after making this Certificate'of Ex.
_ emption,you should become subject to the Workers'Compensmion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QFAL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=0C.FM.) 6.00 SEISMIC FEE
I hereby affirm that tlmre is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenci Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC p
I certify that I have read this application and state that the above VENTILATION'FAN (SINGLE) 4.00 O
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CC"(3 H.P.or 100,000 B.T.U.) 6.00
f Ilcreby authorize representatives of this city to enter upon the 'BOILER-COMP(Ozer 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
' (We) agree to save, indemnify and keep Imnnless the City mL MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ay inany/sny $crue SO, 'nst said City in conseqa of the PERMIT ISSUANCE 10.00
rakh
nting of I(s p( it (�/�ue MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL 1_�
sgnature Of App scan ntmcm le
OFFICE COPY