10809 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
�f ADDRESS 10809
(!).7—o e) L u C( LLC BUILDING— ELECTRICAL—PLUMBING —MECHANICAL
OWNER'S
NAME 7H«-/b A✓C'S0�- PLAN CHECK VALIDATION.-dy� t//� � QTY, ELECTRIC PERMIT FEE -
NE
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 '
LIC.No, LIGHTING FIXTURES 10.00/1.00
ADDRESS TDRs APPLIANCES-RESIDENTIAL 4.00 -
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - - PLAN CHECK FEE - P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. ISIGNS TRANS,. 3.00
ARCH.OR ENG. - - IT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S �P�'',�,_V",
aooREss - � - MOTORS SEE FEE SEH. -
SERVICE CHANGE 20.00 r
w 0 i �r-AG r4l/
Hoo LICENSED CONTRACTORS DECLARATION'. fr``'�
<u Hj I hereby affirm that I am licensed under provisions of Chapter 9 1y V
w a$ (commencing with Section 7000)of Division 3 Of the Business and 1J IS ANCE GATE
H y z Professions Code,and my license is in full Rome and effect'. BLDG. ECT. PLG. MECH.
zO z so License Class Lic.Number �
F w H J Date Contractor lrLP1' �L1I
Qy�
E a i OWNER-BUILDER DECLARATION BUILDING PERMIT
P.
I hereby affirm that I am exempt from the Contractor's License
MISC.— REFER TO ORD INFORMATION
u o¢ Law for
the nychllowingreason.ch(Sec.
requ03 ires
a permit Business and Professions VALUATION $/FT.
Code:Any city or county which reyuiresn permit to construct,alter, PERMIT ISSUANCE
¢w 4 ELEC.CONTR. LIC.NO.
Q o improve,demolish,or repair any structure,prior m its issuance,also ELEC.
i G u requires the applicant t t such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License -
Hz >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
m o Business'and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
rc H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; -- by any applicant fora permits ubjectsthe$500R.licanttoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8 y amp
❑ I,as owner at the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the and
Prof is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menls.,ano(intended or offered for sale,If,however,the building GAS-EA.SYSTEM-11NC.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 of sale.). RES IN❑D CON -'P❑B Ot❑M1er
❑ I,as owner oPthe property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 600 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B.
to an owner ofproperty who builds or improves thereon,and,who LAW_N SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with o oontractons)licensed pursuant to -
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 t TRACT NO. PARCEL NO. .
❑ lam exempt under Sem.,
B,&P.C.for this
anon WATER HEATER W/VENT .6.00
Owner ate WATER SYSTEM - 5,00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DE ARATIO WATER TREATING EQUIP. " 5.00
1 hereby affirm 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 thereof(Sec.3800,Lab.CJ. -
Policy No. Company - I
0 ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24z Z ❑ Certified copy is filed with the city inspection division. _
H O Applicant MISC.- REFER TO ORD. - v N�' J N�
cc N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10:00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.corvTR. LIC.rvo. PLG.
1 0 (This section need not be completed if the permit is for one TOTAL 'Y[3 N� Y ❑ N❑'
Z hundred dollars 0100)or less I
0 0 I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE - FEE SUMMARY
IL U , mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California. y
y Date 'Applicant ALTER OR ADD TO MECH. '5.00 - BUILDING 3O IU
.} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
L., Z' dtiption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the U such provisions or this permit s all ou must forthwith comply it
be deemed revoked w - AIR HANDLING UNIT(TO 10000C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county gO1LER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for representatives
of
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino againstliabilities,judgments, costs and expenses which CONST.TAX
may any way acerue'against said City in consequence of the PERMIT ISSUANCE 10.00
grand f this
MECH.CONT. LIC.NO. MECH.
L 0,
SigneNre of Applicant/Contractor Dao TOTATOTAL
OFFICE COPY ,