11168 APPLICANT-TO FILL IN INFORMATION WITHIN REDLINES — USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BOILDING APPLICATION &PERMIT a ��
AooREss "' � - _I
BUILDING—ELECTRICAL-PLUMBING--MECHANICAL
OWNER'S
Ni PLAN CHECK VALIDATION
QTV. ELECTRIC PERMIT .FEE
PHO
H E WEa UTLETS-SWITCHES-RECEP 10.00/1.00 "
uc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES=RESIDENTIAL •'+ 4.00
•PHONE PANEL$ 10.00 DATE OF APPLICATION
ORLRI ECT " PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER _
' LIC.NO. .SIGNS TRANS. 3.00
ADDR.SS ENG. : 'SPECIAL CIRCUIT 5.00 ,
ARC..OR
PERMIT VALIDATION
ZIP EMP.METER R POLE INS. X20.00
h
APPLICANT'S
APPLICA - MOTORS SEE FSE SCH'. I/`IINy�t—✓'(^
Z SERVICE CHANGE 20.00
o a
Foo LICENSED CONTRACTORS DECLARATION - ,
u 1 hereby affirm that C.,licensed under provisions of Chapter 9
a t (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r w i Professions Cod ���LLLmmmy license.is in'full foLc 1n e t BLDG. E E T. PLG. 'MECH.
2 o w 2 Licens"C s CDR Numb ❑' ❑ ❑
9 0 H w Date CDntraclo
E o w OWNERIL DECLARATION /� BUILDING PERMIT
w ; y I hereby affirm that I am exempt from the Contractor's License 'MISC.— FER TO ORD INFORMATION
LL o¢ Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
� — Code:Any city or county which requires a permit to construct,alter, PERMIT ISSUANCE ..10.00
Z m>E
Ie a a,0 improve,demolish,or repair any structure,prior[o its issuance,also ELEC.CO TH. LIC.NO.
C u requires the applicant for such permit to file's signed statement that TOT
-
71�� TOTAL` PERMIT,TO
a, w m m he is licensed'pursuabl to the provisions of the Contractor's License - e--� y
E.
z a Law(Chapter9(commencing with Section 7000)of Division 30film
i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE i
rc H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR..
dim by any applicant fora permit subjects (500).licanitoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(my amp- • .
❑ I,as owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE r 4.00 x
their Sole compensation,will d0 the work,and the structure Is not i OCC:GROUP RES.UNITS
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
himself or through his own employees,provided that sucso.Pr.FLOOR AREA TOTAL-ACREAGE_ h improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1'1 NC.4 OUTLETS 6.00 "
or,improvement is sold'withio one year of completion,the'owner GAS-EA.SYSTEM-OVER 4 ' ' -
builder will have the burden of proving that he did not build or im- (EA.) 2.00 BUILDING USE 1
prove for purpose of sale.). INDUSTRIAL WASTE INTER. . 30.00 RES IND CON PB 'oma,
r ❑ I,as owner of the property,am exclusively contracting with RE ❑ CO - ❑,
licensed contractors to construct the project(Sec:7044,Business LAWN SPRINKLERS-1 INC 5 V.B.' 6.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) ".1.00
contracts for such projects with a contrtm ods)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. -PARCEL No.
`e❑,nl am exempt under Sec. ;8,&P.C.tui this WATER HEATER W/VENT 6.00 J
Owner Date WATER SYSTEM" a 5.00
ACC.GATE 'ACC.FILE NO.
WORKERS,'COMPENSATION UIiCLARATION - WATER TREATING EQUIP. 5.00 . •
hereby affirm that] have a certificate ofcousent to self-Insure,
or a certificate of Workers'Compensation II sura c,or a grtitied I ZONING ENG,SITE NO.
copy thereof(Sec.3800,Lab.C.). -
- Policy No. Company
0 Certified copy is hereby furors is � '
-�' Cerlify��pryQ� with the i ins ectlon division. _ FIRESPRINK ENERGY T-24
Z
AJ
(ylt✓_ �O L�--• MISC:'- REFER TO ORD. Y N❑ . Y,Q N�
~ rn ° ' PERMIT ISSUANCE .
� — CERTIFICATE OF EXEMPTION FROM WORKERS' .. 10.00 FLOODZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL V N Y N
V O hundred dollars IS 100)or less.) -
1 certify that in the perfurmance of the work for which this per. QTY MECHANICAL P EMIT FEE SUMMARY
LL..I,F mit isAssued„1 shall not employ any person in any manner so as to � FEE
'y •VyW P 'becombSubject`to'die Wdiekers'-Compensatlowl-awn of'Celiforhla . 'Y+^'v'P•^^"' r...` +.:.nimMa -
y Data Applicant - ALTER OR ADD TO MECH. 5.00 . BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of F.x-
♦— 2 emption,you should become subject to the Workers'Compensation App LIANCE 5.00 ' PLAN CHECK
provisions of the Labor Code, you must forthwith comply,with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10ACC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a cmislru.no.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.). FSOILER-COMP
G UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name G UNIT(OVER 100,000 B.T.U.16.50
Lender's Address ELECTRIC
r I certify that I have read this application and state that the aboveLATION FAN (SINGLE) 4.00
information is,correct-'I agree to comply with all city and countyBOILER PLUMBING '
'ordinances and state laws relating to building construction, andCOMP(3_H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter mpon the
above-mentioned ro err for inspection purposes. -COMP (Over 100,000 BTU)SEE FEE SCH. .p P y p P p MECHANICAL
(We) agree to save, indemnify and keep harmless the'City ofREFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any,w ccrue against said City in cons quen a of the ISSUANCE 10,00Iery �/n • LIC.NO. MECH.i� TOTAL TOTAL
a re of p mans/Contractor Oale�
OFFICE COPY