10834 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION* PERMIT NUMBER
BUILDING- APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL - 10834
OWNER'S PLAN CHECK VALIDATION
ry',p�•MjJE� (�'� QTY. ELECTRIC PERMIT FEE
�. `lt•\ ` ` � PHONE
COAAMERACTORs _ 11 OUTLETS-SWITCHES-RECEP. 10.00/1.00
uC.No. ' 1�1 LIGHTING FIXTURES, 10.00/1,00
AOGREss TOR's - _APPLIANCES(`.'g -RESIDENTIAL 4,00
PHONE C PANELS - 10.00 DATE OF APPLICATION
A 1-lelp - PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 -
APPLICANT'S -4
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
H O o LICENSED CONTRACTORS DECLARATION ,
<v I hereby affirm that 1 am licensed under provisions of Chapter'9
z w ISSUANCE DATE
¢ e. (commencing with Section 7000)of Division'3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Code,and my license is in full force and effect.
Z, i w W License Class Lic.Number 31(3 IF El I El
H zo H J Date 2=I_/ Contractor
¢ ac a a
¢ BUILDER DECLARATION OWNER- BUILDING PERMIT
_ w -
wo¢ O INFORMATION
R: y I hereby affirm ithatre so exempt from the Contractor's License MISC.- REFER TO ORD
u o¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
H - PERMIT ISSUANCE 10.00
EE >f Code:Any city Dr coun pair any structure,
requires une,prior
t to construct, also
' -
¢ ¢ ¢O improve,demolish,or repair any structure,prior n its issuance,also ELEC.CONTE. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL
PERMIT TO
e" w m w he is licensed pursuant en the provisions of the Contractor's License
i Z < Law(Chapter 9(co moos Code)or that lie is exempt
of Division 3 mane
f 4 D Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE /
¢ E.$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n3� by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Of at more than five hundred dollars($500h) -
❑ L as owner of the property,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 sale(Sec. 7044, Business and Professions DRAINS-FLOORROOFAR EACON D. 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 F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered for sale.If,however,the building GAS EA.SYSTEM-.1 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 im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES 'IND CON PB Omer
RES.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS 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
wnlracts far such projects with a cm-Ductmos)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAFYMM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SY - 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION - WATER TREATING EQUIP , '5.00 5 I'
I hereby affirm that I have a certificate of consent to self-Insure, /s
or a certificate of Workers'Compensation Insurance,or a certified CI ZONING ENG.SITE NO.
copy thareof(Sec.3800,Lab.C,
Policy No. Company
0 ❑ Certified copy Is hereby furnished. > ,• - FIRE SPRINK ENERGY T-24
Z 2 1) Certified copy is filed with the city inspection division. Y ❑ N❑ Y ❑ N❑
App team MISC.- ER TO ORD.
P: LO PERMIT ISSUANCE 10.00
� - CERTIFICATE OF EXEMPTION FROM WORKERS' FLOODZONE AO.U.C.
LU COMPENSATION INSURANCE PLG.CONTE, LIC.NO. PLG. (�•
CL 0 (This section need not be completed if the permit is for one NOTAL l ~sW Y❑ NEIY E] N❑
hundred dollars($100)or less.)
L) O I certify that in the performance of the work for which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shell not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
W Dale Applicant ALTER OR ADD TO MECH. 5.00 'BUILDING
>- ro NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f- ? emption,you should become subject to 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 he deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 6.00 'SEISMIC FEE
1 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9,50
Lender's Address ELECTRIC '
I certify that I 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-COMP(3H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE'SCH. MECHANICAL,
above-mentionedproperly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino against Dab ti judgments, costs and expenses which PERMIT ISSUANCE _ 10.00 CONST.TAX
ma iri any way ace a inst id City in consequence of the
gr ting of th' arm G MECH.CONT. LIC.NO. . MECH.
2 � 0 TOTAL TOTAL y/l
Is store of Applican/Contractor Dale 1'J