10979 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE B LL POINT PEN ONLY
IT BUILDING PROJECT ID IFIL PERMIT NUMBER
foo Lo, APPLICATION & PEWIT
- 10979
ADDRE
' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O(VN 'I PLAN CHECK VALIDATION
A QTY. ELECTRIC PERMIT FEE
HONE
NANTR DRI /j UTLETS-SWITCHES-RECEP 10.00/1.00
uc.N �7 LIGHTING FIXTURES 10.00/1.00
CONTR 0 I PPLIANCES-RESIDENTIAL 4.00
ADDR /((�J
PHONE l(J(/1 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
AP
ANIf S
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 ,/
�oo LICENSED CONTRA ORS DECLARATION ,/ �'�
K is u I hereby affirm that I am licensed under provisions of Chapt 9 IS UANCE DATE
N<i (commencing with Section 7000)of Division 3 of the Bus' es nd BLDG. ELECT. PLG. MECH.
F y i Eq
Professions Cod nd y It is in full forTIN
aF ❑ ❑ ❑
2 o m- Licen Class Lic.Number
mr w Date Contractor
Q y f J BUILDING PERMIT
5 B,Be u
OW_
ER-BUILDER DECLARINFORMATION
K 3.LL w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
1° a_ Law forthe following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00
VALUATION $/FT.
t - 0 Cade:Any cityorcounly which requires a permit to Construct,after,
re 2 Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. TEL
-O Be requires(he applicant for such permit to file a signed statement that TOTAL PEflMrt O
E
$ he is licensed pursuant to the provisions of the Contractor's License ,I
r 2 i Law(Chapter 9(commencing with Section 700(1or Division 3 of the A
< Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
et I$ (he basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
a- by any applicant for a permit subjects the applicant lop civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($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 FIXTURES-PER TRAP 5.00 so.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-11 NC.4 OUTLETS 6.00
ar improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have Ilse burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,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 LAWNSPRINKLERS-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 WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsenl to self-insure. ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certi 'e
copy thereof(See.3800,Lab.C.
Policy Na Co any
O ❑ Certified copy I ehy d. FIRE SPANK ENERGY T24
Z Z ❑ Certified c py R• pity inspection divis n. MISC.- REF ER TO OR D.
O APplicnnt Y ❑ N❑ Y ❑ N❑
~ ua A.L.U.C.
LU CERTIFICMOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0
W C>_ COMPENSATION INSURANCE: PLG,CONTR. LIC.No. PLG.
C- O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollars(S100)or less.) ' Q q
U O I certify(hat in the performance of(he work for which this per. OTY. MECHANIC JAL PERM�1��1 FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
O 0. Date Applicant - ALTER OR ADD T H. .00 BUILDING
>_ Do NOTICE TO APPLICANT: If,after making this Certificate of I1
? emption.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(T C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 IC 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(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 ROFILM
3097,CN.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 CTRIC
Lender's Address
IcertifY that lhave read this application and late that the above VENTILATION FAN (SINGLE) 4.00 '
information is correct.I agree to comply with all city pad count BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
Ordinances and state laws totaling to building construction, and
hereby authorize representatives of this city to enter upon the 801 LER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
p_bove-mentioned propert 'nspection purposes. -
(We) agree sav Inde nify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag at ilities judgments, costs and expenses which' NST.TAX
10.00
may a y ecru gainst said City in consequence of the ERMIT ISSUANCE 1
gr ting s un' MEC ONT. LIC.NO. MECH.
/A/C a T G OTAL
are of Ap IicantlConlrucfor Date vl .J
OFFICE C6PY