18064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
B ILDmG APPLICATION & PERMIT
{/+.f, 1 •P� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 18'064
OwNEq'S PLAN CHECK VALIDATION
N4ME
r.1 LI�
MONE-7`IIO/111 -DJ OTY' ELECTRIC PERMIT FEE� ,
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
No LIGHTING FIXTURES 10.00/1.00
f,GNTq ACTOq Q. M' fy�
aoogass V . PPLIANCES-RESIDENTIAL 4.00
ONE PANELS 10.00 O
ARCHrtECi - ATE OF APPLICATION "
Oq NSA PANELS (OVER 200 AMP) 20.00 A c c C P.C.NO.
ENGINEER a
LIC.No. SIGNS TRANS. 3.00
AR H. ENG. -
aoogsss SPECIAL CIRCUIT - 5.00 Tr[,AuonrloN
Z EMP. METER OR POLE INS. 20.00
APPLICANT'
sq'i 44
ADDgess MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
00
0c
O O F LICENSED CONTRACTORS DECLARATION
affirm 1 hereby affirm that I am licensed under It of Chapter 9 l•
<a (commencing with Section 7000)of Division 3 of the Raptness and ISSUANCE GATE
F O 2 Professions Cade n m license is in full fo a id f C BLDG. ELECT. PLG. MECH.
z o y - Lice •CI s Lic.Number
L r w Dale- �• ConiractaA [��sf - (�f
Mawat OWNF;R-BUILDER DECLARATION ) Z'�Cr ® o7/O BUILDING PERMIT
u
wINFORMATION
i. A w I hereby affirm that I um exempt from the Cnntmctor's License MISC.- OR
H u O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION
Iw � E Code:Any city or county whichrequiresa permit toconstn¢t,alteq PERMIT ISSUANCE 10.00
S K ¢O impmvp,demolish,or repair any slructur0.prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
i w m u reyuires(he applicant for sudrpermit to fisc a signed statement(hat r TOTAL
hmQhe is licensed pursuant to(he provisions of the COnhndois License PERMIT TO
Law(Chapter 9(commancingwith Sec[ion 7000)of Divlsiolo301'the
E 4 p Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 703 1.5 TYPE CONSTR.
e- 3 m by any applicant fora permit subjects the applicant to civil penalty
of not more than five hundred delta.(SSOO).): ALTER-DRAIN&VENT
-WATER (EA.) 5.00 '
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT
their sole Compensation,will do the work,and tile . DEVICE 4,00 e structure is not OCC.GROUP - RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAWS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 '
himself or through his own employees,provided that such Improve- SQ FT.FLOOR AREA TOTAL ACREAGE
ments 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, the owner- -
builder will have the burden of proving that he did not build or am- GAS-EA.SYSTEM-OVER 4 (EA.) ' 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ae3 IND CON PB Other
❑ d as owner of the property,Le exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors t0 construct the project Law
Bminwe LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The hbuidContractor's License Law docs not who ASSESSORS PARCEL NO.
to tr owner of property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contends for such projects with a contradorl s)licensed pursuant to, -
theContmctor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT I)MV 'Z,0
Owner Date WATER SYSTEM - 5.00
ACC.GATE ACC.FILE N0.
WORK F.RS'COMPIiNSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby,affirm that I have a certificate of conmm to set Ginsure,
or a certificate of Workers Compensation Insurance,nr a cert stied ZONING ENG.SITE N0.
copy Cher;;{{yy((((SGG��}}ffjj00 Lab C.). 1 _ r .
Policy NdL1h&Uany T� 1"L311�
❑ Cerfi lie copy is hereby furnished.
Z 2 Certif• o y 's IL wit I he city-in Ppdion division. FIRE SPRINK ENERGY T24
H 0 /applicant MISC.- '.REFER TO ORD. v N� v N�
L4 CER'rlFIC E FEXLMPTIONFR ORKERS' 'PERMITISSUANCE aQ00 IL•D�
W 1 M ENSATION(NSU RANCE PLG.CONTR. FLOOD ZONE A.L.U.C.
d D LIC.NO. PLG.
Z (This section need not he completed if[he permit is for one TOTAL I ye �� 'Y,� N� Y N�
U Q hundred dollars($100)or less.)
I certify that m the performance of the work for which this per- QTY MECHANICAL PERMIT FEE SUMMARY
W 1- mit is issued,I shall not employ any Person in any manner so as to FEE
O W become subject to the Workers'Compensation Laws of California.
Is. Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} Z NOTICE TO APPLICANT: If,after making it is Cetl ompe sa ton
- provision you should become subject to the Workers Commensal ion APPLIANCE 5.00 PLAN CHECK
provisions io the Labor CGdhall b deemed
comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000OF.M.), 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=QF.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 (his permit is issued(Sec.
30MICROFILM
r' . HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's s s Namam e
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION-FAN (SINGLE) 4.00
udonances is estate.1 agree to comply with all city and county PLUMBING L-yt
ordinances and stale laws relating to building construction, and BOILER-.COMP(3 H.P.Or 100,000 B.T.U.) 6.00 �-L,0d
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and.keep harmless the Cil MISC.
City of -
REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
May i arty way accrue against said City in consequence of the PERMIT ISSUANCE � 10.00
irrant' gofthis trail MECH.CONT., LIC.NO. MECH.
-9 TOTAL TOTAL I o0
I
an cf Applicant/C tract Ua(e
OFFICE COPY