11875 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ���
ADDRESS I�13r
J ��, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER S PLAN CHECK VALIDATION
"AME
(0-0&106=CITY. ELECTRIC PERMIT FEE
µp ooekM.
PHONE
CONTRACTOR:i , UTLETS-SWITCHES-RECEP iO.00/1.00
NAME
W esG _ Coed..f 1 U Kbly\ LICNO. LIGHTING FIXTURES 10.00/1,00
GD.EaOroFs
AS PPLIANCES-RESIDENTIAL 4.00 '
ADDRES
PHONE ' PANELS 10.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
OR R• K0.�'Gr . 69595" PANELS (OVER 200 AMP) 20.00
ENGINEER
UC.NO. SIGNS TRANS. 3.00
ARCH.SS 8 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
,�, (pgrj rrEMP. METER OR POLE INS. 20.00
Ars
ADDDRESSDRESS MOTORS SEE FEE SCH.
Uy -
SCk� C SERVICE CHANGE 20.00 {/t
ore . LICENSED CON'(RACTORS DECLARATION �, "CE DATE
a U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE.
Z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
0'Jri
i Professions Code,and my license is in full force and effect. E) ❑ � ❑
a: O - License Class Lic.Number
O m - D Dam Contractor -
a y i BUILDING PERMIT
IcIca OWNER-BUILDER DECLARATION
A o a" MISC.- REFER TO ORD INFORMATION
w ;u I hereby affirm that I am exmnpl from the Contractor's License VALUATION
. Hoo Law for the following reason.(Sec,7031.5,Husinessxnd Prof:Dons PERMIT ISSUANCE 10.00
w Code:Any city or county which reyuiresapermit toconstroMaltcq
a 'eY ELEC.CONTR. LIC.NO.
E a Q improve,demolish,or repair any structure,toff prior to its issuance,than TOTAL- DLL requires the applicant for sueh permit ns file a signed actor's i that TOTAL /-a) P�ERMITTO
E
$ he u(Chapter
9(court to the provisions of the )ofDkisior License / e"sCJ
H z r Law(ess and
9(commencing Code)or Section is exempt
therefrom
the ` -
a Business for Professions empt or that he is tion of therefrom and CITY. PLUMBING PERMIT FEE
by-By
apli the afore exit taubn.Anhe*applica ufSedbn 703L5 STORIES TYPE CONSTR.
by any applicant for a permit dollars the applicant too civil penalty -
ofnot mor<than fivchundred dollars(55001.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
Cl I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 5cc.GROUP RES.UNITS
their side compensation,will do the work,and the structure u 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 does such work FIXTURES-PER TRAP 5.00 SCLU.FLOGRAREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
mems are not intended or offered for sok.If,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 am- BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IND CON PB Omer
01,as owner of the property,am exclusively contracting with El El Ellicensed contractors to construct the. project(Sec.7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 A ESSORSPARCELNO.
and Professions Code:The Contractor's License taw dues 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 ontractom s)licensed purstmnt to
the Contractor's Lme Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam cyavgpt ndc Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
ret
Ow Dun WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
s WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby Afiml that 1 have a cerlificate of consent to v'Igin sure, �t ZONING ENG.SITE NO.
or a cc,tificatc of Workers'Compensation Insurance,or a certified
copy themof(Sec.3800,Lab.C.).
Policy No. Company ` „
❑ Certified copy is hereby fumished •'r I' ~ UCIa FIRE SPRINK ENERGY TQe
Z Z ❑ Ceniflad copy is filed with the city inspection division.
O Applicant e - MISC.- REFER TO' D. Y ❑ N❑ Y ❑ N❑
CC LO CERTIFICA'f1i OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE ;(JIBGI{Inl% 10.0 (J FLOOD ZONE A.L.u.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
D. 0( chis section need nod he complmed if the permit is for ono TOTAL 6 Y❑ N❑ V ❑ N❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, 1 shall not employ any Penton in any manner so as to
Ow become subject to the Workers'Compensation Laws of California.
a Drc ApplicantBUILDING
>_ N NOI ICE TO APPLICANT: If,after making this Cerlificele of Ex- ALTER OR ADD TO MECH. 5.00
H ? caption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U wh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M-) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNII(OVER IQOOOC.F.M.) 6.00 SEISMIC FEE
I hereby affiml that there is a construction[ending 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 H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
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. I agree to comply with all city and runty PLUMBING
ordinances and sure laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of thus city to enter upon the BOILER-COMP Over 100,1%108TU1SEE FEE SCH. MECHANICAL
Wve-mentioned property for Inspection purposes.
(WeI agree to save, indemnify and keep harmless the City of MISC.-m REFER TO ORD.
Cupertino��xgm biMtisl judgments, costs unit expenses which PERMIT ISSUANCE - 10.00 CONST.TAX
may in fy wa accrue vat said City in consequence of the
gr>�lia f i ermlt. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
S a[urc o(Applicanl/Contractor Uedc '
OFFICE COPY