10096 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION . PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
p(40 OH�C?� '� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10096
OWNER'$
PLAN CNEC VALIDATION
- NAME QTY. ELECTRIC PERMIT FEE
!Z L -')( HONE .h\
CONTRACTOR 31,e,T U - .00
TLETS-SWITCHESRECEP 10.00/1 I
i `
fil L. LIC.NO,t 2 LIGHTING FIXTURES 10.00/1.00
aooeess ons p ) PPLIANCES-RESIDENTIAL 4.00
PHONE Z� •Q// PANELS 16.66 DATE OF APPLICATION
ARCHITECT
ORPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
zm TEMP.METER OR POLE INS. 0.00 O
ADDRESS s MOTORS E FEE SCH-
SERVICE CHANGE `
O ¢ z ) y
F O 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��T•�p s
ri w I hereby affirm that I am licensed under provisions of Chapter 9 e I ISSUANCE GATE
a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D i Professions Code.and my license is in full forcepp4 effgct7 Z 3 d !8-/fl[�j�J O
O 0 ut o License Class L U Lie.Number El ❑ ❑
Date--- - Contractor
Pt
¢ ¢ Ce < OWNER-BUILDER DECLARATION BUILDING PERMIT
X 3 LL I- 1 hereby affirm that 1 am exempt from tile Contractors License
MISC.- REF ER TO ORD INFORMATION
LL O¢ Law for the following reason.(Sec.7031,5,Businessand Professions VALUATION
t - -+ PERMIT ISSUANCE 10.00 SIFT.
Code:Any city or county which structure,
requires une permit toconstruct,,also
2 T.0 p improve,demolish,or repair any structure,prior m its issuance,also 4LEC. NTR. LIQ NO. ELEC. q (/Y
y w m u requires ne applicant for such revisit to file a signed statement that TOTAL 00 PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License �7�
r z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the FEE / C ��'�
4 0 Business and Professions Code)or that he is exempt therefor,and PLUMBING PERMIT
¢ r m the basis for the alleged exemption.Any violation of Section 7031.5
STORIES TYPEC ITR.
a 3 � by any applicant for a permit subjects the applicant lou civil penalty
cfaot more than five hundred dollars(5500).): LTER-DRAIN&VENT-WATER (EA.) 5.00
us owner of the property,or my employees with wa6es usACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure n not OCC.GROUP RES.UNITI
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.001 1
Code:The Contractor's License Law does not apply to an owner of
Ir property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.Pr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such im Provo
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,tire owner-
builder will have the burden of proving that he did not build or i," GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
BUILDING USE
prove for purpose of tile.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ d as owner of tire properly,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors m construct the project La 7044,of apply LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law doer not apply gSSEII0R5 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 contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec..,B.&p.C.for this
reasonWATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORKflRS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby aPfum that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
_ copy limmof(Sca 3800,Lab C.).
O PTY No. Company
PTY
Certified copy is hereby furnished,
Z Z ❑ Cert ificd copy i+ tiled with clic city inspection division. FIRESPRINK ENERGYT-24
F, O Applicant MISC.- REFER TO ORD. Y ❑ N� Y [3 NE]
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
W > COMPENSATION INSURANCE. PLG.CONTR, LIC.NO. PLG.
CL O (This Section need not be completed if the N
2, p permit i+ for One TOTAL V N E] Y
hundred dollars(S 100)or Icssy
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL� mil is issued,1 shall not emNn an OTY. MECHANICAL PERMIT
y' y person In any manner so as to FEE
Q w bccoOILy eyt o}Y Workers'C t,,,,I,,n Laws ofC ifona.Dmc.(CZOApplicant ALTER OR ADD TO MECH. 5.00 BUILDING
tail NOTICE TO APPLIGAN'I': If,aftZ ilii r ificaI- x-
emption,you should become su cor s Car
t-n APPLIANCE 5.00 PLAN CHECK
U such provisions or this;rovisions of thehpermor �dsha he Jecmdd re you in e ku1 comply wit AIR HANDLING UNIT(TO 10 FEE
,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10J"OEM.) 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 Perini[ is issued(Sec.
3097,Cm.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Z^a-
I certify that I haveread this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby authoriz representatives of this city to enter upon the
ahovomentio property for inspection purposes. BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) ago 0 save, indemnify and keep harmless the City'of MISC.- REFER TO ORD.
Cupertino rest liabilities,judgments, cost,and expenses which
may in a way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
granting this permit. MECH.CONT. LIC.NO. MECH.
TOTAL
IgA' rl'OI ApphCan(/COrltmClOr Date TOTAL
OFFICE COPY