11115 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NO PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDREss 11115
'O BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
t L~s' I OWNER5 PLAN CHECK VALIDATION
$. I CITY. ELECTRIC PERMIT FEE
,. PHONE
NONine ncTOR's Qi OUTLETS SWITCHE ECEP 10.00/1.00 0
uc,No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES
4.00
ADDRESS
PHONE PANELS 10-0070 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN-CHECK P.C.NO.
OR
E NGINEEP
uc,No. _ , SIGNS TRANS. 3.00
ARCH.
oo'ESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS.
APPLICANTS MOTORS SEE
ADDRESS ll
SERVICECHANGE 24,(700
M o 4, (70
LICENSED CONTRACTORS DECLARATION l0 7�b
<u U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
x w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
z Z Professions Code,and my license is in full force and effect. Ity El ❑
z o'� License Class Lie.Number
2 m r o Date Contractor
BUILDING PERMIT
Ica w a OWNER-BUILDER DECLARATION INFORMATION
o A ca MISC.- REFER TO ORD
E:
;u y I hereby affirm that 1 am exempt from the Contractor's License VALUATION S/FT.
H LL o a
Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00
-' Code:Any city or county which requires permit to construct,alter,
re U Q Q Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC. LIC.NO. ELEG L 'r (N
d y K requires the applicant for such permit l0 file a signed Statement that TOTA (T9 r2L.. T" PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License ti
Hi >
Law(Chapter 9(commencing with Section 7000)ol'Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
t$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fur a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
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 Ib an owner of 1
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-
menlsare not intended oroffered for sale If,however,the build ing GAS-EA.SYSTEM-11NC.4OUTLETS 6,00
? or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or am- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ 1:1 C3 11
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 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.
❑ 1 lam exempt under Sec..,B.&P.C.lot this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKIi RS'COMPFNSA' O DECLARATIO WATER TREATING EQUIP. 5.00
1 hereby affirm that I have u eertireme of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lab.C.).
Policy No. Company - I
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y N� y NO
O Applicant
1- N PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� j CERTIFICATEOFIiXIiMPTION FROM WORKCRS'
Ill _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o (This section need not be mmpkted if the permit is for one TOTAL Y❑ N Y❑ N
D Z hundred dollars IS 100)or less)
L) 0 I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL P 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 j
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /
} to NOTICE TO APPLICANT: If, Her making Ibis Certificate IT Cx-
F ? emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK few' t
provisions of Die Labor Code, you must forthwith comply with FEE L� .
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNI 0=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH U T) 5.00
the performance of the work for which this permit is issued(Sec. EATING UNIT 0 HO B.T.U. 8.00 MICROFILM
3097,Ci,C.). }{ p
Lender's Name .HEATI NG UNIT( ER 1000 .)9.50 1-01
O
Lender's Address ELECTRIC .-�'�oZ
'h" f I certify that I have read this application and slate that the above VENTILATION FA ) 4.00
r information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and
BOILER•COMP(3 H.P: x100,000 B.T.U.) 6.00
) •' hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE BCH. MECHANICAL ��
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
in any way acerae,ag'nsl sa'd City in consequence of the PERMIT ISS NCE 10.00
vd
ITT Of(his penitiL MECH.CONT.,F ! LI .NO. MECH.
5if, /'�`� �/n OTAL �oL TOTAL
pplle Cn Ira or Dale 13 W f J
OFFICE COPY �( `•Z,�_.