10244 APPLICANT TO FILL IN INFO_ " TION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJEe7TI DENTI FICATI APPLICATION SE PER PERMIT NUMBER
BUILDING I O8 1�I E„ye r.'y[L�j J
G x! De- BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 0244
OWNER'S OC eC• '
PLAN CHECK VALIDATION
NAME Y\ 0.1yoe y OTV ELECTRIC PERMIT FEE ,
RSCONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 �-- ,
Fit Ma OC EIC NO. 23LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADD[�Ess c� � ut P_ APPLIANCES-RESIDENTIAL 4.00DEC q ip C
r.'o .V6,0 If- k-3ku MHONE (mak 2."742. PANELS 10.00 �DA E FAdQ.ncA11oN
ARCHITECT c�Y N CHECK FEE
ENGINEER P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
LIC. Ceoertin
c.No. SIGNS TRANS. 3.00 0
ADDRESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 WWW"
ADDRESSTs `, MOTORS SEE FEE SCH. (� p
�7� !� r VIeLJ SERVICE CHANGE 20.00
0 0 o LICENSE[)CONTRACTORS DECLARATION TEMP.POLE 30.00
a ii. I hereby affirm that 1 am licensed under provisions of Chapter 9
w G h (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
L G. ELECT. PLG. MECH.
H m z Professions Carl it rr9�{y'I�'cen0,is in full filoo, e(fey� O ❑ ❑
z o x - License Class -- L.� Lie.Number L b 73�
w F w Umc I 1_ O_�o__�ComndorR
wa OWNER-BUILDER DECLARATION BUILDING PERMIT
° a O MISC.- REFER TO OR
INFORMATION
,xu ;u I hereby affirm that 1 am exempt from Ola Contractor's License
u O sl Law for lire following reason.(Sec.7031.5,Businessand Professions DALUATION _i/FT
- i PERMIT ISSUANCE 10.00
Colic:Any my or county which requirese permit issuance,
also
improve,demolish,or repair any stratum,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL
w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
rzQLaw(Chapter 9(Commencingwith Section 7000)ofDivision 3 of lite
x a Business and Professions Code)or that he isaxempt therefrom and QTY. PLUMBING PERMIT FEE 1Ul/
F_$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i3 - by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars 15500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the Property,or my employees with wages as BACK FLOWPROTECT. DEVICE 4.00
their sole Compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
'mended or offered for sale (See. 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 docs such work F IXTURES-PER TRAP 5.00 $O.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improves
menfs are not intended or offered for Sale.D,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement Is sold within one year of completion,the Owner-
builder (EA.)will have the burden of proving that he did not build or ion- -- BUILDING USE
Prove for 1,a,owner
of tiled' INDUSTRIAL WASTE INTER. 30.00 t❑ N
❑ L c owner of the properly,am exclusively Contracting704 , with
B Done,
licensed contractors to construct the Project La 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSEBS RS PARCELNO.
El 11
and Professionswneof Code:The honb undo o License Law docs non apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a mmraaurls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ 1a exempt under Sec.-,IL&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK F RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sel&insrc,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy l hereof(See 38p�,Lab C.).
Policy Nnldd�-]: AIA
111pary beaver T .< .
O ❑ Certified copy ishereby furnished FIRE SPRINK ENERGY TZ4
z Z Certified Copy s Bled SII the city inspection di once.
FO npicam�n Idrv,-ia /�., ,,,,..� MISC.- REFER TO ORD, F__
N� v� N�
� `� CERTIFICATE OF Ii XF.MPTION FROM WO PERMIT ISSUANCE 10.00 ZONE A.L.U.C.
LLI > COMPHNSATION INSURANCE PLG.CONTE. LIC.NO. PLG
EL O (This section need not be completed if.the permit is for one TOTAL NY ❑ N�
::) Z hundred dollars IS 100)or less.)
L) O 1 cenlfy out in the perform air CC of me work for which 01 is per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U heconle subject to the Workers'Compensation Laws of California.
UJ
0. D°n Applicant ALTER OR ADD TO MECH. 5,pp BUILDING
} W No tWE TO APPLICANT: If,utter making this Certificate of Ex-
♦- Z cnlplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.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 lire work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 t
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 t
mtlmances n comet.1 agree ti comply b with all city and county PLUMBING
nnlinanees and slate laws rulming to building on an and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon th° BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
heave-mentioned property for insp of
this
purposes.
(We) agree to save, indemnify and keep bmmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue agai aid City in consequence of the PERMIT ISSUANCE 10.00
gran Sig this permit MECH.CONT. LIC.NO. MECH.
TOTAL
Sig u of Applicant/C raTOTAL
dor Date
OFFICE COPY