11418 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE'BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT _
JR41 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ' 11418
1_reeVWaj
O srs'o, - PLAN CHECK VALIDATION
NAME QELECTRIC PERMIT FEE
1` E�J R D -P.Yava1 HONE 737 11244 TY.
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIGHTI
LIC.No. NG FIXTURES 10.00/1.00
'
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 �
AOOR E SS
PRONE PANELS 10,00 DATE OF APPLICATION
ARCHITECTANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENa SPECIAL CIRCUIT 5.00 IDATION
ZIP EMP.METER OR POLE INS. 20.00 OUL 9
AO REAS a - MOTORS SEE FEE SCH, 13136
SERVICE CHANGE 20.00 see
+�l ty 0/Cu -
W o o LICENSED CONTRACTORS DECLARATION s �rt(/IQ
a U w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Busines and - BLDG. ELECT.
Z0 de
vL MECH.
r D Profesiom,Co, and my license is in full force and effect ❑
Z o svj' - License Cl ass Lic.Nam re, _ - El 0
O z - Uetc Contruclor
¢ y f - . BUILDING ERMIT
¢ re re OWNER-BUILDER DECLARATION INFORM TION
oA MISC.- REFER TO ORD
K
LL F I hereby rl Firm that I am exempt (Pont the Contractor's License Vq WNFON S/FT.
HU04 Lawlor the following reason(Sec.703L5,Businesand Professions PERMIT ISSUANCE 10.00
Code Any city or County which requires o permit to construct,alter,
is ¢¢ 2 improve,demolish,or Perri,any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
ca - O ¢ requires the applicant for such Permit to file a signed statement that TOTAL RMIT TO
A ww he is licensed pursuant to the provisions of the Contractor's License
H z ae
a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IS the basis for the alleged exemption.Any violation of Section703L5 STORMS T PE ONSTR.
d ; _ by any applicant for a permit subjects the applicant toecivil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(SSOOI):
❑ 1,as owner of the properly,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 wlc (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License law does not apply to an owner of
r properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SC.FTCLOOR AREA TOTAL ACREAGE
v himself or through his own employees,provided that are improve-
Jim%Rperal
arot tended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 6.00
isold within one year e f completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 Bu1LDING uSE
will have the burden of proving that he did not build or im- RES INO CON PB Ontofor purpose of sale.). INDUSTRIAL WASTE INTER. 30.00' El IN 1:1I,as owner of the property,am exclusively contracting with F-1 El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSE $PARCEL NO.
and Professions Code The Contractor's License Law does 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 contractorts)licensed pursuant to SEWER-SANITARY-STORM V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
11 ere pRl er Sec. ,B.&P.C. br this WATER HEATER W/VENT 6.00
, Owner
Date WATER SYSTEM 5.00 t2 ACC.DATE ACC.FILE NO.
N'ORKERS'COMP ATI DECLARATION WATER TREATING EQUIP. 5.00
I hemby affirm that 1 have a certificate of consent to self-insure,
or a Certificate of Workers'Compensation Insurance,or a certified ,d alfr ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnish d. FIRE SPRINK ENERGY T 14
z Z ❑ Certified copy is Filed with the city inspection division.
O Applicant MISC.- REFER-ToORD. y ❑ N� r ❑ N[J
.CC to CERTIFICATE017 IiXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0.C.
UJ > COMPENSATION INSURANCE PLG.CONTR. sec.NO. PLG. It Y-1 N O r N�
_ (This section need not be Completed if the permit Is for one TOTAL
hundred dollars(S)OO)or lc..)
U O I Certify that in the performance of the work for which this Per- QTY. MECHANICAL PERMIT a FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any roomer so as to
U become subject to the Workers'Compensation Laws of California.
O i Daze ApplinntALTER OR ADD TO MECH. 5.00 BUILDING
} Us NOTICE TO'APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provulons or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0MC.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ,C.),
Lender's Name HEATING UNIT(OVER 1 D0,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 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 county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OD P(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOvar 100,000 BTU)SEE FEE SCH. 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 CONST:TAX
May in any way acme against Said City in CTce of the PERMIT ISSUANCE 10.00
gran[i0 f[hB r �L MECH.CONT. LIC.NO. MECH.
q TOTAL TOTAL
Signs BIG.of Ap Ilcantf n Pact r Dat
OFFICE COPY
CITY OF CUPERTINO OFFICE
COPY
GAS SERVICE NOTICE
E
19
LL I TO
You are hereby authorized to connect the GAS service for
m
Owner or Tenant
New Service
o /
8 No. of Meters - Reconnect Y
N I No. of Add. Meters _Move Service
I)
Move Meter
PLUMBING INSPECTOR AL1�01� /