11684 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11684
Ao7R 5:
` BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
.NER'S PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
UAII fF PHONE
NOOINTRACT RsMEUTLETS-SWITCHES-RECEP 10.0011.00 Q 'C9
rn,�he;s f LIGHTING FIXTURES 10.00/1.00 70 --
CONT EMtuns Lf ag APPLIANCES-RESIDENTIAL 4.00
nkf ,r d Da PHONE 1441�/9)9 PANELS 10.00 DATE OF APPLICATION
ORRcwTecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK E P.C.NO.
ENGINEER
sec.No. SIGNS TRANS. 3.00
ARCH,
oo EOR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS _ MOTORS E FEE SCH.
ADDRESS
g� SERVICE CHANGE PAO 20.00
woo LICENSED CONTRACTORS DECLARATION bra
1jO
Q ul Ihereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vHi z .0 (commencing with Section 7000)of Division 3 of the Business and
CLT BLDG. ELECT. PLG. MECH.
1- 0 x Professions Code�aV y license E in full for c 1110
z O 2 - LicenseClass Lic.Rumba � � ❑
9 i2 r Delc - Contractor,
a mBUILDING PERMIT
ao i u OWNER-BUILDER DECIARA'FION INFORMATION
w ; u m I hereby affirm that I am exempt from the Comraclor's License MISC.- REFER TO ORD
FLL0 < WVALUATION
wfor the following reason.(Sec.7031.5,Businessend Professions PERMIT ISSUANCE 10.00 - S/FT.
Code:Any cit y or coun ty which req uiru a ems i t to constmct,alter,
6 ca < improve,demolish,or repair an structure,prior to its ismance,also ELEC.CONTR. LIC.NO.
O pY CI O ELEC. p/q�
O IL requires the applicant for such permit to rile a signed statement that PERMIT TO
u w he if licensed pursuant to the provisions of the Contractor's License
i Law(Chapter 9(commencing with Section 7000)of Division 3 of the E -vl
a Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for ePermit subjects the applicant tea civil penalty ALTER-DRAIN III VENT-WATER IEA.) 5.00
of not more than Five hundred dollars(5500).):
❑ I,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, Basin,.and Profusions 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 6.00 IA FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
' / meats are not Intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS.6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that he did not build or im- . . .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Ower
❑ 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
contracts for such projects with a contractors)licensed pursuant to SEWER-SAN EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ .I am exempt under See.-,BL&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsenl to wirinsure, ZONING .ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ceri0ed
copy thereof(Sec.3800,LA.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z = ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
~ ✓+ PERMIT ISSUANCE 10.00
CC - CERTIFICATEOF EXEMPTION FROM WORKERS' FLOOD ZONE q.L.0 c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL _ (This section need not be completed if lire permit Ls for one TOTAL Y❑ N❑ Y ❑ IN F]
hundred dollars(5100)or less.)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL U mil is issued,I shall not employ any person in any manner se as to
becom•subl ctI he WOrkcrs' mpensat( n ofC lilpfniy� BUILDING
i Dale_r__t �_V.Applicant g 1'7d7[lFF fC ALTER OR ADD TO MECH. 5.00
} w NOTICE 1'O APPLICANT: II,after nsaking this Certificate of Ex-
f" = emptier,you should become subject to the Workers'Cmr,m,atmm APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mel forthwith comply with FEE
V
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOQF.M-) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1OX0C.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(See. MICROFILM
3097.CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 p
Lenders Address ELECTRIC
I certify that I have read this application and slate that the above. VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and stale lows relating to building construction, and B0ILER-CONP(3H.P.or100,000B.T.U.) 6.00
1 hereby authorize representatives of this city to enter upon the
shove-mentioned property for inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 1p,pp CONST.TAX
may in any way accrue against said City in consequence of the
granting of lhu permit MECH.CONT. LIC.NO. MECH.
/g-gG TOTAL TOTAL
S in re of Applicant/Contractor Date
OFFICE COPY