17886 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
ADDBUI LDING ROJCT I DENTI FICATION
PERMIT NUMBER
fC 17886
L APPLICATION & PERMIT
BUILDING — ELECTRICAL—PLUMBING-MECHANICAL .
OWNER' PLAN CHECK VALIDATION
NAME lc n G QTY. ELECTRIC PERMIT FEE
PMONE ACJ
CONTRACTOR'S
N.AME OUTLETS-SWITCHES-RECEP 10.00/1.00
pallf 0 JLIGHTING FIXTURES 10.00/1,00
CONTRACTORS - - APPLIANCES-RESIDE
4.00
Amon Ess
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
_LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT .5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 20.00
ADDRESrvr'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 4v�V1til hCi'
O O O LICENSED CONTRACTORS DECLARATION -
`� a u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE OATS
Z
y (commencing with Section 7000)of Division 3 ol'ti a Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. MAy ❑ ❑
o i w W License Class Liu.Number El
F w H J
Dart,—Contractor yy''
OWNER-BUILDER DECLARATION CRY at IY BUILDING PERMIT
ode' MISC.— REFER TO ORD INFORMATION
X 0 m 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
H LL o ¢ Law for the following reason.(Sec.7031.5,Business and Professions - PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to conslruet,alter,
¢ ¢ a2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERM TO
F
$ he is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapter 9(conartencingwlthSection 7000)ofDivisam3.1tire C�WG
¢ Business unit Professions Cello or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section7031.5 STORLFS TYPE CONSTFIF
a ; by any applicant,for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.antis
their sole compensation,will Jo 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 SQ FT,FLOOR AREA TOTAL ACREAGE
himself or through his ownemployees,provided that such improve-
ments1 are not intended or offered for sale.IL lmwever,the building
or improvement is sold within one year of completion,the owner,
r--� GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int RES IND C N PB Orher
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 Contractmr'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 Joe such projects with a contractorls)licensed pursuant to SANITAR V 200ft/1000
- -STORM EA. .
the Contractor's License Law. SEWER
/ t TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
0 a5Ull
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC,FILE NO.
WORK ERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby at that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers Compensation Insurance,or a certil'icd ENG.SITE NO.
copy thcomf(See.3800,Lab.C.). � All
Policy No. C"IMPTION
O ❑ CertifiC eJ. FIRE SPRINK EN ERGY T-24
Z Z �CeRifi c c s •'t , division. MISC.- REFER TO ORD.
Q Applicant Y � N Y ❑ N❑
I— y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CIi RTIFIION PROM WORKERS'W � INSURANCE PLG.CONTR. LIC.No. PLG,
CL O (phis Section need not he completed if the permit is for one TOTAL 7e 0 O Y F] N❑ Y N❑
Z) Z hundred dollars($100)or less.)
V O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H' mit is issued,I shall not employ any person in any manner so as m
U become subject to the Workers'Compensation Laws of California. -
y Daus Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} GO NOTICE'f0 APPLICANT'. If,after making this Certificate of Ex-
F Z option,you Slould become subject tm the Workers'Compensation APPLIANCE 5.00 'PLAN CHECK
'provisions of the Labor Code, you muss forthwith comply with FEE
C) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 4,00
1 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEI SMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work I'or which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address-
1 certify that I have read this application unJ vmc that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city.1,111 county - PLUMBING ( / Y
budinences and slate laws relating to building construction, and BOILER-COW(3 H.P.or 100,000.B.T.U.) 6.00
hereby, authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ab'avomenlioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
ar
H Cupertino against fablit S,judgments, cosh and expenses which CONST.TAX
may any w' cru agai t said City in consequence of the PERMIT ISSUANCE 10.00
1. pe n'. MECH.C . LIC.NO. MECH. '
TOTAL TOTAL 17OQ
of licam/Contractor Date
M
OFFICE COPY .