18357 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION - ,-APPLICATION S1 PERMIT ^ 1� r
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1 O4l BUILDING-"ELECTRICAL-PLUMBING-MECHANICAL
' upMER9 O PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
NEyys-o7aa
NAMECONT -1 UTLETS-SWITCHES-RECEP 10.00/1.00 3,.
C.NO. LIGHTING FIXTURES 10.00/.1.00 '
CONTRACTOR'S p'
III AOOREss'l�bpd AJA I ��J�}1.?r+U O� PPLIANCES-RESIDENTIAL 4.00 _
PHON y PANELS 10,00 DATE OF APPLICATION
ARCHITECT •A_ �,� I). � PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR fC.Q
ENGINE R
LIC.�Nxo1.'�• SIGNS TRANS. 3.00
AARCHf Do DDRESS ENG1jOQ3 V1 coin✓wmew SPECIALCIRCUIT - S,OO PERMIT VALIDATION
44Z Llligl) ilP%b V TEMP.METER OR POLE INS. 20.00 l� V
APPLICANTS � MOTORS SEE FEE ADDRESS .
-
Lfp SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION - W s (10 I�L'`F.`' (' VO's
a i aa
u 1 hereby affirm that I am licensed under provisions of Chapter 9 - 'ISSUANCE DATE
y<% (commencing with Section 7000)of Division 3 of tire LD
e Business and BG. ELECT. PLG. MECH.
F N i Professions Code am my license is in full force an effce ❑ ❑ ❑.
Z 0 m- License lass t Lie.Number - -
0 m)_ Date
�Contmdo
BUILDING PERMIT
¢ Q w OWNF: )ER DECLARATION DECLARATION - INFORMATION
se ;e-N I hereby affirm that I am exempt from the Contractor's License MISC.- _ RD VALUATION $/FT.
F w o J Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 p�7
Z; Code:Anycry or county which requires a permit to construct,alter,
a,¢Y improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ,�x ''11
w o rt requires the applicant for such permit to file a signed statement that TOTAL _a 0 C, PERMIT TO
n K m a- be is licensed pursuant to the provisions of the Contractur's License o
Fii Law(Chapter.9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
EE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONS R.
d3 _ by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
_ intended or offered for sale(Sec. 7044, Business aad 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 FIXTURES-PER TRAP 5,110 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON FB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
D 1,as owner of the 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
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. r
O lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner ��+�Iy Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
�RK S'CDMP:NSATION DECLARATION WATER TREATING EQUIP. 5.00 _
I ereby affirm that'I have a certificate of etmxent to sell'-insure,
or:I crtificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy eaf(Sec 3800,Lab.C.L Q s,..
Policy No.-Company54v
oe cema
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
�/ Ccuifled buy is BIS-d w1 I �h• ity
Z p nd'lj licant ,'yEtl( �(,Cc - MISC.- REFER TO ORD. Y ❑ N❑ _ Y ❑ N❑
CC T CERTIFICATE EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. '
�
Z I chis section need not be completed if the permit is for one. TOTAL Y❑ N❑ Y❑ N❑
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per, QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mitis issued,I shall not employ any person in any manner so as to _
U become subject to the Workers'Compensation Laws of California.
Is. Late Applicant ALTER OR ADD TO MECH. 5.00 BUILDING -
} to NOTICE TO APPLICAN"f: If,after making this Certificate of Ex-
? -
eruption,you should become subject to the Workers Compensation APPLIANCE - 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 10p00CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.EM.) 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 workich this permit is issued(Sec. 'MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's No HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction;and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP 10ver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
' Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
mNlpg of thi rmiL MECH.CONT. LIC.NO. MECH.
TOTAL ., TOTAL DQ
i [urea pplicrai tractor Ua
OFFICE COPY