11035 APPLICANT TO FILL IN INF&ATION WITHIN RED LINES - USE o1LL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PE IT 035
DURESS
O 6, N a� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O.NER's O PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
T PRONE
GOTRACTORSOUTLETS-SWITCHES-RECEP 10 /1.00
SNS104S sec.ND. LIGHTING FIXTURES .00/1.00
r-ONTRACTOR'S APPLIANCES-
RESIDENTIAL 4.00
ADDRESS /J��I/� IL
II SItC44MN PHONar0-IbG PANELS 10.00 DATE OF APPLICATION
1 ARCHITECT PANELS (OVER 200 AMP 20.00 PLAN CHECK FEE P.C.NO.,
Q O ENGINEER
Lie.NO, SIGNS TRANS. 3.00
Z Q ARCR'E9s ENG. SPECIALCIRCUIT 5.20 PER MIT VALI DATION
M ZIP EMP.METER O OLE INS. 20.00 n
`! APPLIDORCESS
ANTS
ADDREss MOTORS SEE FEE SCH. U
✓�
C, Alb CONTRA4TVIERS SERVICE C ANGE 20.00
w02 LICENSED CONTRACTORS DECLARATION o�J
a U 1 hereby affirm that I am licensed under pio
rovisns of Chapter 9 ISS A DATE
I-z w (commencing with Section 7000)of Division 3 of the Business and
y a BLDG ELECT. PLG. MEC
H z Professions Cod• an{�u license is in full force f•'tn�LGG ❑ ❑ ❑ �'
0 o m - License '_�_/.✓ Lic.Number_ /4I
m -�� Date-'�uG'1a�.�_Contraclor .S
r
a y v BUILDING PERMIT
a DWNIi R-BUILDER DECLARATION
o a INFORMATION
wLL y I hereby affirm that I am exempt from the Cuntracior's License MISC.- REFER TO ORD
u o a Law for the following reason.(Sec.7031.5.Business and Professions VALUATION S/FT.
- mom Code Any bityorcounty which requires a permit m construct,alter,
PERMIT ISSUANCE 10.00
rtQ 0 imprrve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- D u requires the applicant for such permit to file a signed statement that TOTAL
n w m w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
r z a
Law(Chapter9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT EE r
I-$ the basis for the alleged exemption.Any violation of Section 703 L$ STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5-96
of not more than five hundred dollars($500L):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE .00 OCC.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,CON 5.00
Code:The Contractor's License Lew 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-
memsara not intended or offered for sale.l L however,the building GAS-EA.SYSTEM-1 ETS 6.00
m
or improveent is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER EA.) 2.00 BUILDING USE
buitdbr will have the burden of proving that he did not build or im-
Z prove for purpose of sale.). INDUSTRIAL WASTE IN R. 30.0
licensed 0 RES IND CON PB Ouse,
Z ❑ I,as owner of the properly.am exclusively contracting with
ensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
O and Professions Code:"rhe Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLER -OVER 5(EA.) 1.00
Q Tcontracts for such projects with a contractor(s)licensed pursuant m
the Contractor's License Law. SEWER-SAN ITARM EA.200ft/10.00 TRACT NO. PARCEL NO.
7„ M ❑ lam exempt under Sec.-,B.&P.C,for this WATERHEA RW/VENT 6.00
reason
M Owacr Date WATERS TEM 5.00 ACC.DATE ACC.FILE NO.
•f� WORK ERS'COMPENSATION DECLARATION WATE REATING EQUIP. 5.00
Y� I hereby:ll-nm that I have u ac,tifi,ale ,Cc on sent to nett-inant, ZONING ENC.SITE N0.
or a cthereof( of Workers'Comm,ly r II�r r'.I certified
copy thereof(Sec 3800,rs'Co)i7 11�Py
Policy No. Company_ 'OZ
❑fryrtilieA copy is hereby furnished' FIRE SPRINK ENERGY T 24
Z
z/ �CertificJ Is fled with he cit inspection division. MISC.- REFER TO ORD.
Cf Applicant-_ _ Y NEI , y ry�
~ w_+ PERMIT ISSUANCE 10.00
CER'I'IP AT'IS OF ISXI PTION ROM WORKCRS' FLOOD ZONE A.L.u.C.
L COAIPENSA'I'ION INSURANCE PLG CONTR, LIC.NO. PLG.
D' O (This section need not be completed if the permit is for one TOTAL Y❑ NEI Y ED N
D Z hundred dollar,IS I OsTor less.)
U O I certify that in the performance of[lie work for which this per- MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of Cldifornia.
Date 'Applicant BUILDING
>_ ED NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F z emplion,you should become subject to the Workers'Compensation APPLIANCE F M COIV VMM; 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such Prussians or this permit shall be deemed revoked. AIR HANDLING UNIT 1 C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLINGUIN ( 10=C.F.M.16.00 SEISMIC FEE
I hereby affirm that mere is a construction lending agency for EXHAUST HOOD(W T DMC 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT 00 B.T.U.) 8.00
Lender's Address HEATING UNIT(OVER 1 .)9.50
� Lender's Address � � ELECTRIC
I certify that I have read this applicalion and state that the above VENTILATION FA 1. I LEI 4.00
information is correct.1 agree to comply with all city and county BOILER-IbAgP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating m building construction, and
herby authorise representatives for ins of this city es enter upon the BOILER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp of
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 Q - CONST.TAX
may in any way accrue against said City in consequence of the
grantin f this permit Q�I//j}�� MECH.CONT, LIC.NO. MECH.
AS, re of Ap ' ant/Co n[rac- ior�1)�,r4 Ay fiz 30�..25 TOTAL / / TOTAL
OFFICE COPY J (( re