10129 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LID I NG PROJECT I DENTI FICATI ON PERMIT NUMBER
eULOmG APPLICATION & PERMIT
? ADDRESS L j_TorJ 10129
/ TT BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME � 1 QTY. ELECTRIC PERMIT FEE
N AGaI'� vnorvE �_I
NAMERAcioRs UTLELG FI-SWITCHES-RECEP 10.00/1.00
LIC LIG
c.NO. HTINXTURES 10.00/1.00
ADDRESS Tons APPLIANCES RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE •P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIE.NO. SIGNS TRANS. 3.00
ARCH.ss ENG' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S C
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Of. 1`
¢
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yaw tcommencing with Section 7000)of Division 3 of the Business and PAWBLDG. ELECT. PLG. MECH.
H 0 a Professions Code,and my license is in full force and effect. ❑
z ,or Clan Lic.Numher
o y CrtarDate
J ❑ ❑
M w OWNER-BUILDER DECLARATION BUILDCNG PERMIT
MISC.- REFE INFORMATION
w ' H I hereby a0 um that I am exempt from the Contractor's LicerLu Q
FLL¢O� Law for the following reason.(Sec.7031.5,Bushressand Professions - pERM1T ISSUANCE 1000 VALUATION $/FT.
vs Code:Any city or county which requires a permit to conmrucL eller,
2 ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. M _
wO¢ requires the applicant for such permit to rile a signed statement that - TOTAL 3 t/ PERMIT TO
r$ he is licensed pursuant to the provisimts of the Contractor's License /.
r z i Law(Chapter 9(commencing with Section 70DO)of Division 3 ofthe
1 4 o Business and Professions Code)or that he is exempt thcrclimn end GTY. PLUMBING PERMIT FEE /
ce r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for.permit subjects the applicant to a civil penalty
Of not coots than five hundred dollars 051X)J) ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 ace.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Profusions 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 tlmrcon,and who does such work FIXTURES-PER TRAP 5.00 Sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS.-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove 1,as o posemer of the.). RESc INDUSTRIAL WASTE INTER. 30.00 ❑ 1❑ ❑N ❑ O❑
❑ L u owner of the properly,he exclusively contracting with
licensed contractors In construe the project(Sec. 7064,business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contracmr s License Law docs not apply ,
to an owner of property who build,or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u comractors)licensed pursuhnt to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL No.
❑ I an,exempt under Sec._,B,&P.C.for this
reason WATER HEATER W/VENT 6.00
OwneraT7aaj71 /J.L'- 0- WATER SYSTEM $.00
ACG DATE ACG FILE NO.
W'ORKERS'COM PF,NSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have acerti0cate of consent I,, ,If-insure,
or a cemificide of Workers'Compensation Insurance,or u ec,lir,d ZONING ENG.SITE NO.
copy thereof1Sec.3800,Lab.C.).
Policy No. Company
❑ Cetlilied copy is hereby furnished FIRE SPRINK ENERGY T-}<
Z 2 U Certified copy is filed with the city inspection division.
PO Applicant MISC.- REFER TO ORD. Y❑ N V ❑ N❑
CC W CERTIPICATEOF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
LL > COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
CL z (This sectitin need not be completed if the permit is fur one TOTAL Y E] N E] Y E] NE]
0 Z hummed dollars IS 100)or less.)
U O I-certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, 1 shall not employ any person in any manner m as m
U DO become subject to the Workers'Coml smation Laws of California.
U 0- Dat` Applicant ALTER OR ADD TO MECH. 500 7 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
.
F ? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply' with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNTT(OVER IQOOOQF.M.) 6.00 SEISM IC 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
Lenders Address HEATI NG UNIT(OVERI 00,000 B.T.U.19.50 ELECTRIC S
_ I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct, 1 agree N comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COtvP(3 H.P.or 100,000 B.T.U.) 6.00
of this hereby authorise representatives ths city enter upon the
herebymentioned propertyfor vesp of purposes. LER-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
may i an a accrue PERMIT ISSUANCE CONST.TAX
yh q y way against said City in consequence of the H.
gran[in of fllu pbrmif MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicon t/ mractor 0 e
OFFICE COPY
1