10716 APPLICANT TO FILL IN INFO&TION WITHIN RED LINES - USE BALL POINT PEN ONLY
'13UI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ED NC APPLICATION & PE
AODRw10 716
�♦ a00RE5$
,vgS L �,� DOI VD BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
I
CANNER PLAN CHECK VALIDATION
I- NAAME� 4y,� {/. /� OTY. ELECTRIC PERMIT FEE
: e l7h�ZA- �C %// ' PRONE '730- /�1L
NAME cTORs UTLETS-SWITCHES-RECEP 10.00/1.00
NAME �>(/
D. .>/7N'es LIC.NO./j /IE L31;I- LIGHTING FIXTURES 10.00/1.00
nooAEs`sroRs Jy-'f�
APPLIANCES-RESIDENTIAL 4.00
p `�L.t �ir LAj PHONE J// 2.743 PANELS 10.00 DATE OF APPLICATION
ARCHI T r PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ON CI d-
SCCI LIC.No. H001 SIGNS TRANS. 3.00
nooAEss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00 \
avvucaNrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CON'T'RACTORS DECLARATION
¢it 0 1 hereby affirm that I am licensed under provisions of Chapter') ISSUANCE DATE
h < uwAi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code./'11d my license is in full force pd aCfeM. 2 ❑ ❑ ❑
Q v,w o License Cl �S'- Con Number 1c,V J
O H w Datc J LC � Conlmaor- bfl:
a x f LA
BUILDING PERMIT
¢ ¢ w ¢
OWNER-BUILDER DECLARATION
o A REFER TO ORD INFORMATION
Wm 1 hereby alfirm that 1 so exempt from the Contractor's License MISC.-
; Oj Law the following reason. 7031.5,Business and Professions VALUATION S/FT.
t - Code:Any city or county whichrequiresa permit toconstrucl,alter, PERMIT ISSUANCE 10.00
QQ ¢ 0 Improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
r z a
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe S7dl vr_epJN/TqQ.
f 4 o Business and Professions Code)or that he is exempt therefrom andCITY. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONST .
w. !.a by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500)I:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oce.GROUP RES.UNITS
their 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-
mentsarenotintended oroffered for sale.11,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA) 2.00 BUILDING LInrvG USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Our.,
Prove for purpose ol'sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ El 111:1❑ 1,as owner of the property,a exclusively contracting with
licensed contractors to construct the project(See 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 SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
Cl I am exempt under Sec.-,BAP.C.for this WATER HEATER WI 6.00
reason
Owner Date WATER SYSTEM 5.00
ACG DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATI P 5.00
] hereby affirm that I have a certificate ofconsmu to self-invmu, �� )j L11 /_/Jug ZONING
a certificate of Workers'Compensalion Insurance,or a cetlifilsl ENG.SITE NO.
py they `So�� b.G.). /�gr6U,1u 7-
co
Po,y t �ap` pony
Cert111lV'Cdpyil l •reby furnished. FIRE SPRINK ENERGY T 24
Z 1¢ev,tified copy is filed with the city inspection division. MISC.- REFER TO ORD. y N v N
❑ ❑ ❑ ❑
~ w PERMIT ISSUANCE 10.00 FLooD zoNE AL.u.c.
2 CERTIFICATIi OP EXEMPTION FROM WORKERS'
111 > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG yQ E� ❑ ❑ ❑ ❑
CL O (This section need not be completed if the permit is for one TOTAL d Y N V N
Z:) 2 hundred dnllan IS 100)or less.)
U O 1 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 to
U become subject to the Workers'Compensation Laws of California.
0 n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. ? 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 shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MIC.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 the work for which this permit is issued(Sec. HEATING UNIT LTO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l 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 3o
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby amhoriec representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property 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 CONST.TAX
may in any way accrue against s'iit City in consequence of the PERMIT ISSUANCE 10.00
gran[m f this permit. ' MECH.CONT. LIC.NO. MECH
AL
TOTAL
Signature of Applicant/Corm vt or - Uato
FFICE COPY