11401 APPLICANT TO FILL IN IN R11 AI�INPR D LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AO ///6r, BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 11401
PLAN CHECK VA LIGATION
QTY. ELECTRIC PERMIT FEE
C V vHorvE
gONTRAC oa's nUTLETS-SWITCHES-RECEP 10.00/1.00
LICLIGHTING FIXTURES 10.00/1.00
TOR'S //�//aJ,/N' hJ///y//$'�/�y�/J� PPLIANCES-RESIDENTIAL 4.00
/ " `/' •Z✓—_ —PRONE
PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20,00 PLAN CHECKFEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRRESS ENG' - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APP cANrs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
O
,-2 LICENSED C NTRACTORS DECLARATION
,t hereby affirm that I am licensed under provisions of Chapter ISSUANCE DATE
HQ w (Commencing with Section 700LI�gC,Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r 7 i Professions Co tan i IM c��yIl full fortolI
x O H — License CI s on umber
9 — Gale r Clmitor
J BUILDING PERMIT
a y f J
IS IS w a WN-R-BUILDER DECLARATI N INFORMATION
wo TLa MISC.— REFER TO ORD
3 u r 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F a-N Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
] ,A> f Code:Anycityor county which requires a permit to construct,alter, ELEC.CONTR. LIQ NO.
it ¢ a O improve,demolish,or repair any shuclure,prior to its issuance,also ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant en the provisions of the Contractor's License .D �t
i z r
Law(ChapterProfession,
Code)orth Sect ton is 00)exempt
D ivlelan3Of the P
is 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
E. H $ by basis any
talc alleged exemption.Any applicant
DOG
703L$ STORIES TYPE CONSTR.
E. by any a..tita fore permit subjects theapplicanl lea civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than flue hundred dollars(5500).):
❑ I,as owner of the properly,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, Rosiness and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such workFIXTURES-PER TRAP 5.00 0 SD.FT.FLOOR AREA TOTALACREAGE
himself or through his awn employees,provided that such improve-
mmGAS-EA.SVSTEM-11NC.40UTLETS 6.00
es are not intended or offered for sale.If,however,the building
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 im- flE5 IND CON PB Other
for purpose of sale.). INDUSTRIAL WASTE INTER3000
❑ I,as owner of the property,am exclusively con Racting 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 docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.1 1,00
Contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's r such
h prof c Law.
O Iain exempt under Sec. ,B.&PC.I'or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent la sell insure, (� ZONING ENG.SITE NO.
or a certificate FW rker'Comp notion Ins ranee,or testified
i
P . S' IC ny') P�
Cerlil'ic copy is hereby Irnished. s FIRE SPRINK ENERGY i24
Z Z A caerl ilii coy ed with x 'i inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ ry❑
O
c y CERTWICATEOF XEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. ��/..II��,�j 9q' 4 PLG.
d O (This section need not be completed if the permit is for one ff O TOTAL / .� Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less'.)
U O 1 certify that in the performance of the work for which this per' QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I shall not employ any person in any Inanner so as to
U become subject to the Workers'Compensation Laws ulCalifornia.
0 a Date ApplicantALTER OR ADD TO MECH. 5.00 fj BUILDING
} rn
NOTICE TO APPLICANT: If,after making this Certificate of Ex-
)... ? 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 slhall be deemed revoked, AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is it 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.CJ. HEATING UNIT(T0 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.0 Q( d
information is correct. I agree to comply with all city and county PLUMBING /J
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T- .)
hereby authorize representatives of this city to enter upon the BOILER-COMP IDVar 1 OB k H. MECHANICAL /� -��t
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless tale City of MISC.-
Cupertino against liabilities,judgments, costs and expenses which �y CONST.TAX
may in any way eerue tiamat said City in On quince of the PERMIT IS UA 1 0 C/
gr mingO thi per iL MEC CONT. LIC.NO. MECH, uJ
���/ TOTA`5 TOTAL ^
Si lure ori ale (�
OFFICE COPY