12009 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BOLDING APPLICATION & PERMIT
ADDRESS 11101 Chadwick Place12009
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S .. PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
Carrie Dyer PHONE 253-0604
CONTRACTOR'S
Ir NAME jjam�,,,� UTLETS-SWITCHES-RECEP 10.00/1.00
At.188 �eatuag , , NO.465266 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS - _l p PPLIANCES-RESIDENTIAL 4,00
(.DpBEs$„DIOlflsrcial EiyA PHONE 739-0516 PANELS 10.00 DATE OF APPLICATION
1A5RCCHIHITEECCT Y PANELS (OVER 200 AMP) 20,00 PLAN CHECK P.C.N0,
OR
ENGINEER '
-. LOC.NO. SIGNS TRANS. 3.00
NOODFES$ENO, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
APPLICANT
MOTORS SEE FEE SCH.
/
SERVICE CHANGE 20.00 j�•
woo LICENSED CONTRACTORS DECLARATION
U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N se n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
6
r D Z Profeiions Cod ngw license is in full for -
z o u� Licen 1611 tic.Number - ❑ ❑ ❑ ❑
9 m f w Date Contractor
a m f BUILDING PERMIT
G Xw u OWNER-BUILDER DECLARATION INFORMATION
I
o n H 1 herebyaffirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
' P VALUATION $/FT.
uoa Law forthe followingreason.(Sec.1031.5,Business and Professions PERMIT ISSUANCE 10.00
E FA sA Code:Any city or county which requires permit to construct,alter,
uw Q improve,demolish,or repair 30y StmClOre,prior 10 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractors License ./
r z i Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING'PERMIT FEE
rc ti-D the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.)'5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
(heir 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- GAS-EA.SVSTEM-I 6.00
meats ere'hot intended or offered for sale.If,however,the building
.'(?. or improvement is Sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im- REB IND CON PB Omer
prove for purpose of sale.). I INDUSTRIAL WASTE INTER. 30.00
❑ 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
to an owner of properly who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contractsfor hprojects with acontroctorls)licensed pursuant 10
the Contractor'sctor'sLicense Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. i ,B.&P.C.for this WATER HEATER W/VENT
reason
Owner Date WATER SYSTEM 1,45M I ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREA INCy 5.
I hereby affirm that I have a certificate of consent to self-inslue ZONING ENG.SITE NO.
or a ce�rtiffiiccaatte of Workers'Compensation Insurance,or a certified
copPeAtC9✓'T�—W.bmpahy Allied
O Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z Certified copy Asx Gled$wi lh lite city inspection division. MISC.- F ORD. Y❑ N❑ Y ❑ N❑
O Applicant GI19 -
rnPERMIT ISSUANCE 10.00 PI.oODZONE A.L.u.c,
LU CERTIFICATE KATECOMPENSATION
EXEMPTION PROM WORKERS'
d NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
O ❑ N❑ ❑ ❑
(This section need not be completed if the permit is for one TOTAL Y Y N
0 Z hundred doll ars IS 100)or less.)
U O I certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT 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 Workers'Compensation Laws of California.
w Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} y NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compcosalion 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 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=11F.M.) 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 work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I 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 county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000STU)SEE FEESCH. MECHANICAL 40 �
above-mentioned properly 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 o- CONST.TAX
may in any way accrue ainst said City in consequence of the
granting MECH.f this permit CONT. LIC.NO. MECH.
Atlas 46s266 TOTAL 18"00 TOTAL
Signature of Applican Cont Cfor Date
OFFICECOPY