11967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aDILD' APPLICATION & PERMIT
ADORES BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
WDA VISTA - QuOk"OWNERS* PLAN CHECK VALIDATION
JC
N" OTY. ELECTRIC PERMIT FEE
�f51 � NE
'v"_C`fi CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
J
LIC.No. LIGHTING FIXTURES 10.00/1.00
ScrOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OF
ENGINEER .
LIC.NO, � SIGNS TRANS. 3.00
ARCH.ORENG. 500 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT ,
ZIP EMP.METER OR POLE INS. 20.00 I
AODRESS n - MOTORS SEE FEE SCH. I�QI�'OA
ADDRESS
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION D-ZL-YG xI4_&
¢ H
a U C I hereby affirm that I am licensed under provisions of Chapter 9 V""`-56& L ISSUANCE GATE
(commencing with Section 7000)of Division 3 of the Business and ` BL ELECT- PLG. MECH.
H w i Professions Cade,and my license is in full force and effect. (b LR I/'Cd 1
o 0 m O License Class-Iia Number- I .�J� - LI tl a pb 1 ❑ ❑ ❑
2 y Ow Dale Contractor �(
¢ ¢w ¢ OWNER-BUILDER DECLARATION "� BUILDING PERMIT
MISC.- REFER TO ORD INFORMATION
w;u y' I hereby affirm that 1 am exempt from the Contractor's License VALUATION
H LL O J Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE10.00
m a Code:Any city or county which requires permit to construct,eller; '
¢Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. • LIC.NO. ELEC.
i -0 w u requires the applicant for such permit to file a signed statement that - TOTAL PER T TO m he is licensed pursuant to the provisions of the Contractor's License
FZQLaw(Chapter 9(commencing with Section 7000)ofDivisiun 3 oftbe
Business and Professions Code)or that'he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M r the basis for the alleged exemption.Any violation of Section 7031.5 - - STORIES TYPE CONSTR.
i3 � by any applicant for a pemtit subjects the applicant tun civil penalty- ALTER-DRAIN&-VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLSWFAOTECT. DEVICE 4.00 OCC.GROUP . RES.UNITS
their sole compensation,will do the work,and the structure isnot
intended or offered for sale(See. 7044,Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Code:The Contractor's License Law does not apply t0 an owner of
property who builds ar'improves thereon;and who does such work FIXTURES-PER TRAP '5.00 SO.FT:FLOOR AREA TOTAL ACREAGE
• menta'are not hrough
ownemployees,for Sale.
If,ed that however,
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or'impare not intended w offered for sale.If,however,the budding
or der will have
is sold within One year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUI_DIN USE
builder will have the burden of proving that he did not build or am- RES IND PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
��yy 1,as owner of the property,am exclusively contracting with ❑. F-1 ED F-11(cL ed contractors to construct the project(Sec.,7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSU7 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 contractors)licensed,conant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lamexemptunder Sec. ,B.&BC.for this WATER HEATER W/VENT 6.00
rens
Own Date WATER SYSTEM 5.00
.ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 _
I hereby affirm that I have dcerlilicate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No.-Company
-
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z D Certified copy is filed with the city inspection division.
O Applicant MISC.-. REFER TO ORD. Y ❑ N❑ Y rv❑
UJ= y CERTIFICATE ON EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE' A.L.U.C.
-
W > COMPENSATION INSURANCE ' PLG.CONTR. LIC.NO. . PLG. ,
1 O (This section need not be completed.if the permit is for oneTOTAL Y❑ N❑ Y C] N❑
D Z hundred dollms($100)orI.S.) s
L) 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 person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 to Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making INS Certificate of Ex-
F-Z enmtion,you should become subject t0 the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 _
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOPWC.F.M.) 6.00 SEISMIC FEE
Ihereby 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 C.). HEATING UNIT ITO 100,000 B.T.U:) .8.00
Lender's Name -
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have readthis application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
,,%thereby authorize representatives of This city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
. I 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 an way accrue against said Cit PERMIT ISSUANCE - 10.00
y y g yin consequence of the
granting oft 's permitMECH.CONT. LIQ NO. MECH.
1 TOTAL .TOTAL '
Signature of ApplicA1717ontractor Care
OFFICE COPY