11868 APPLICANT TO FILL IN INFC�ATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PEMPT
AOOREsVo rr, A/I �)E/1/z9 L✓ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 11868
OWNER'S w Gx7 O /Nn/ PLAN CHECK VALIDATION
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NA
9` - QTY. ELECTRIC PERMIT FEE
Cor CTOHa 5 OUTLETS-SWITCHES-RECEP 10.00/1.00
.11, uzZ LIC.No. 1Q LI GHTIN 3 FIXTURES 10.00/1.00
/ ADDRE1CTDR's SS APPLIANCES-RESIDENTIAL 4.00
' PANELS 10.00 DATE OF APPLICATION
-h TECT-. PANELS (OVER 200 AMP) 20.08 PLAN CHECK FEE P.C.NO.
/ OR ttIITT''
ENGINEER
sec.No. SIGNS TRANS. 3.00
ADDRESS ErvG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AP Ndrlss sNrf s MOTORS SEE FEE SCH. _yD C.
A
O I ,• ✓1 /
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION
v U I hereby affirm Ihut 1 am licensed colder provisions of Chapter 9 ISSUANCE DATE
or a N (commencing with Section 7000)of Division 3 of the Business and n_ BLDG. ELECT. PLG. MECH.
H w z Professions Cod• d��myyy nse is in full f. - pt
z o m - License Class-"LZ Lie.Number (Cll ❑ ❑ A❑ / ❑
0 z F w Dme Contructor 6w
a x E (�r,T •, BUILDING PERMIT
�.w u OWNER-BUILDER DECLARATION INFORMATION
o MISC.- REFER TO ORD
X3 n n I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F .. o a Law for the following mason.(Sea]031.5,Business and Professions PERMIT ISSUANCE „10.00(O�f! L'1
Code:Any city or county whichrequimsa permit toconstrucl,olter, G
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO, ELEC. �f 1 /
- O LL requires the applicant for such permit to file a signed statement that TOTAL OCOI� PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License �•
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Ei o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
s- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; m by any applicant for u permit subjects the applicant full civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
C11,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 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,AR EA,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 FIXTURES,PER TRAP 5.00
thSO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mentsarenotintendedorofferedforsale.11,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.(. RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,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 Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
con tons for j
p
such projects with a«ndrmtorts)licensed pursuant to
the Contractor's hroLicense Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Ium exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORKERS'COMPHNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a eenificule of consent In sclibinsu re. ZONING
or a certificate of Workers'Curppensatim\nsurance or certified ENG.SITE NO.
copy they o ISec. B00„Lp4.C�'
Policy N G fB By
O ❑ Cen 's hereby forms ed. FIRE SPRINK ENERGY T 24
Z_ Z ❑ C Ified file u c ..y ins ,_division. MISC.- REFER TO ORD.
O Appllca w Y ❑ N❑ Y ❑ N❑
cc Fy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
CERTI CATH:OF EXEMP"HON FROM WORKERS'
LLI > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
CL 0 ('this section need not be completed if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or lcssJ
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued.I shall not employ any person in any manner so as to
OU become subject to lire Workers'Compensation Laws of Cslifurma.
w N(`
2 Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
NOT
} ti NOTICE 'HO APPLICANT: If,after making this Certificate sa Ex-
♦- Z eruption,you shouldbecome subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U
provisions theeLabor Code, you must forthwith comply with FEE f0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 70,000OF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE .571
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(TO 700,000 B.T.U.) 6.00 MICROFILM
3097,Civ.CJ.
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 .(/L
Lender's Address ELECTRIC
I certify that I have read this apcomply and slate that the above - VENTILATION FAN (SINGLE) 4.00
inkhOrdinances o correct. I agree to comply with all oily and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state lows relating to building construction, one
hereby authorize representatives moves of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wo) agree to save, indemnify and eep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities, 'u it lsai costs and expenses which CONST.TAX
Ca ' way accrue ga rst a icy in consequence of the PERMIT ISSUANCE 10.00
anting t is omit. MECH.CONT. LIG NO. MECH.
l -123-�/o TOTAL TOTAL lis 73
or of Applican t/ ontr to Date
OFFICE COPY
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