09743 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POI NLY
BUILDING PROJECT I DENTI FICATION - PERMITNUMBER
ADDRDINGESS APPLICATION & PERMIT O^ 7,4
ADOREss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9 I
1017.1 Imperial Ave.
OWNER'S
NAME PLAN CHECK VALIDATION
Imperial Printing ' 4O8-255-106 TY• ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
NAME C-10 OUTLETS-SWITCHES-RECEP 10.00/1.00
Y
CEC Electrical CQL1tIB.N0,456029 LIGHTING FIXTURES 10.00/1.00
ADDRESS TOR topbell, CA. APPLIANCES-RESIDENTIAL 4.00
P.O. Box 9952 374-2312 PANEL$ 10.00 /0 DATE OF APPLICATION
OgclotecT PANELS (OVER 200 AMP) 20.00PLAN CHECK FEE P,C.NO.
ENGINEER
LOC NO. SIGNS TRANS: '3.00 ' '
ARCH.OR ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS.• 20.00 q
ADDRESS MOTORSSEE FEE SCH:
SERVICE CHA GIfPAIn 20.00 9
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 7 �CL3/���
a u I hereby affirm thm I am licensed un der provisions of Chapter 9
y a y (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
F y z Professions Codean rpY I'cense is in full for - ,;t;I W
BLDG. ELECT. PLG. MECH.
o i w W License a q.,xk, (J_Lic.Numher,.,(yj �I•`� City of Cupertino
m H Dale -1.-J( Contractor L.M. C C
Qyf
Is Ie w ¢ OWNER-BUILDER DECLARATION + e ' BUILDING PERMIT
U - INFORMATION
w r. w I hereby affirm that I am exempt from the Contractor';License MISC. REFER TO ORD
u o ¢ Law for the following reason.(See.7031.5,Business and Professions VALUATION $/FT.
I -m PERMIT ISSUANCE 10.00 0
w� E Code:Any city or county which requiresa permit to construct,alter, - '
¢ Q D improve,demolish,or repair any structure,prior to its issuance,also' ELEC.CONTR. Y� LIC.N0. ELEC. f/1'
DLL req WfCa the applicant 5nCh Permit lO file a$Ig11 L•d statement that �CEC Electric 456029 TOTAL PERMIT TO
a w m u he is licensed pursuant to the provisions of the Contractor's License - Ed -G�
FiQ Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe
x 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE e
¢ s-$ the basis for file alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a. by any applicant for a permit subjects the applicant tma civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).1: -
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDflAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does Such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself.or through his own employees,provided that such improvc.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or int- GAS-'EA.SYSTEM-'OVER 4(EA.) 2.00 BUILDING USE
prove for purpose ofsaleJ. RES IND I CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codu:The Contractor's Liccnae Law docs not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
0 lam exempt under See!-,N.&1'.C.for Ibis
reason WATER HEATER WENT 6.00
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.PILE NO:
WORK Ii RS'COMPI:NSATION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate ofconsent to self-insure, _
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE N0.
copy Ih 3800 Lah.C. ,,, -P,,
Policy C npa Y _61 J11$.-
❑ Cerlifie py he Ir sled. -
Z'Z. ❑ Celli 'op is the ci inspection division.
FIRE SPRINK ENERGY T 24
F O Applicant MISC.- ' , REFER TO ORD. Y NO Y 0 No
� N CFRTIFICATE OF EXEMPTION OM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.Lu.C.
COMPENSATION INSURANCE' - PLG.CONTR, LIC.NO,
LU O PLG.
CL a (This section need not be completed if the permit is for one TOTAL Y N Y N
hundred dollars(S I OO)or less.)
s ) O 1 certify that in the performance of the work for which this per. OTV MECHANICAL PERMITFEE FEE SUMMARY
IL F Gilt is issued, 1 shall not employ any person in:my manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
0. Dam Applicant ALTER OR ADD TO MECH. 5.00
} 2 NOTICE TO APPLICANT: If,after making this Certificate Of I:x�
-
♦- - emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Or visions of the Labor Code, you must forthwith comply with FEE
U such it provisions or this permshall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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(Sec. MICROFILM
3097,Civ.CJ, None HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000B.T.U.M.50 ELECTRIC
I certify that I have read this application and stale that IIIe above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county .PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property far inpectimn purposes.
(We) agree so save, indemnify and keep harmlem the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
May in by yay acjrue against said City m consequence Of the PERMIT ISSUANCE' 10.00
gran Ii f 1 6 pen 1. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
nature of Applicant/ onfraclor - )are
OFFICE COPY