The URL can be used to link to this page

11935 APPLICANT TO FILL IN INI*MATION WITHIN RED LINES - US[ LL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION 3 PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRE%/o 61-.� 11935 I/ BUILDING- ELECTRICAL-PLUMBING -MECHANICAL OWNER'$ q PLAN CHECK VALIDATION (� :A-PA �• `` PHONE J$^Q/' QTY. ELECTRIC PERMIT FEE � V CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 NAME LIC.NO. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'SRESS APPLIANCES-RESIDENTIAL 4.00 PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER uc.No. SIGNS TRANS. 3.00 ARCWORENG. SPECIAL CIRCUIT $,QQ PERMIT VALIDATION nADOnESS v EMP. METER OR POLE INS. gA1r-20.00 0 n , ADDRESS MOTORS SEE FEE SCH. /� SERVICE CHANGE 20.00 '. woo LICENSED CONTRACTORS DECLARATION <u w I hereby affirm that I am licensed under provisions of Chapter 9 I n•t,r nF P11Do{['j 1 ISSUANCE DATE v, < y (commencing with Section 7000)of Division 3 of the Business and n 111 BLDG. ELECT. PLG. MECH. r• y z Professions Code,and my license is in full force and effect na.r AQ Ci.Qe�t ❑ ❑ ❑ ❑ z o m- License ClassLic.Number yr r o Date C.In ucmr ¢ x E BUILDING PERMIT ¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION wDAD MISC.- REFER TO ORD S u 1 hereby affirm that lam exempt fw.5 the Contractor s License VALUATION $/FT. s- uo ¢ Lt.for the ity or countywh(Sec.7ires a Business mdProl'essions PERMIT ISSUANCE 10.00 O Code:Any city or county which requires a permit to construct.utler, 2 Q improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.or 0 Dil A. KO u requires the applicant for such permit to file a signed statement that TOTAL .l VV PERMIT TO La m he is licensed pursuant to the provisions of the Contractor's License ��>> Uzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the ��'//pr �LLzr"!tL ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE it - $ the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 of not more then five hundred dullms(5500).1: ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 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,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 F IXTUR ES-PER TRAP 5.00 SD.FT,FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 6.00 ments are not intended or offered for sale.It,however,the building 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 popsy, y gwith INDUSTRIAL WASTE INTER. 30.00 El 0 ❑ ❑ ❑ ❑ 1,as owner of the t am exclusively conractin licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B- 6.00 and Professions Code:I'lie Contractor's License Law does not applyASSESSORS PARCEL NO- 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 contructor(O licensed pursuant to the C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ Iumexemptuoder Sec. B.&P.C.tirrthis WATER HEATER W/VENT 6.00 reason Owner_ _ //��//-�I�k4 Dute �' WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ' :%XftlNI SAT'ION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a cerliticvl ENG.SITE N0. copy Ihereof(Sec.3800,Lab.C.). Policy No. Company O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24 Z Z ❑ Certified copy is tiled with the city inspection division. O Applicant MISC.- REFER TO ORD. Y [] N❑ Y ❑ ND CCN CERTIFICATE 017 EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W > COMPENSAT ION INSURANCE PLG.CONTR.- LIC.NO. PLG. Y N Y N❑ CL 0 (This section need not be completed if the permit is for arc TOTAL hundred dollars IS 100)or less I U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY LL I- mit is issued, I shall not employ any person o,any Inarne,so us to U become subject to the Workers'Compensation Laws of California, U Ul Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } w NOTIC17'1-0 APPLICANT: If,after making this Certificate of Ex- (_. 2 emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK provisions of the tabor 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 AIR HANDLING UNIT(OVER 10)000C.EM.) 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. MICROFILM 3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 3o Lender's Address ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. 1 agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SC H. 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 PERMIT ISSUANCE 10.00 CONST.TAX \ ma any way accrue against said City in consequence of the / MECH.CONT. LIC.NO. MECH l . , g x TOTAL TOTAL atur o APPlicant/Contractor IAte OFFICE COPY