11063 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTI FICATI ON PERMIT NUMBER j
BUILDING APPLICATION & PERMIT ( �._
ADDREBE 11063
d C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME /f CITY. ELECTRIC PERMIT FEE
�v(,� vworvE 1`i
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
'}Q 1 C uc.No. p0 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SQf Lolpo FI�L-112 O PPLIANCES-RESIDENTIAL 4.00
ADDRESS J
xQ-,r PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 2400 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.ND. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTSMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE A 20.00 - q
Foo LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUAN E DATE
m Q i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N i Professions Code,an�n license is in full fume ecL q ❑ ❑ El
O,A - Lure lass �-- Lic.Number .Ff 6 u
O Datc Contractor
z z o n
a x f L CI� BUILDING PERMIT
M I,n OWNER-BUILDER DECLARATION INFORMATION
w g LL y I hereby affirm thot I am exempt from the Contractor's License MISC.-- REFER TO ORD
p VALUATION SIFT.
H LL 0 j Law for the following reason.(Sec.7031.5.Business and Professions pERM1T ISSU CE 10.0010
Code:Any city or county which mquiresa permit to construct.alter, �---,
R Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �.
O u requires the applicant for such permit to file a signed statement that TOTAL �Fj PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
H z Q Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe A-TR-
i 4 0 Business and Professions Code)or t `1hat he iSexempl therefrom and CITY. PLUMBING PERMIT FEE
RHP the basis for the alleged exemption.Any violation ofSection 7031.5 1 STOR IES TYPE CONSTR.
i ;m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).).
❑ 1,as owner of the property,or my employees with wages as BqSX FLOW PROTECT.DEVICE 4.04 OCC.GROUP RES.UNITS
(heir sale compensation,will do the work,and the structure I,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 F IXTUR ES-PER TRAP 5.00 s0.F.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.It,however,the building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING
builder will have the burden of proving that he did not build or im- RES IND C PR ohne,
prove for purpose of sole.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ D
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 A O SPARCEL 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 contmetods)licensed Purslant to SEWER-SANITARY-STOR .200ft/10.00 TRACT NO. PA O.•
the Contractor's License Law.
❑ I am exempt under Sec.-.BAPC.forthis WATER HEATER W/ 6.00
reason
Owner Date WATER SYSTEM atv 5.00 ACC. A - ILEN .
WORKERS'COMPF-NSATION DECLARATION WATER TREATI I 5.00
I hereby affirm that I have a"Dific:De nl'conxenl to sclf-insure. �dlrno N G.SIT l
or a ecftificale of Workers'Compensation Insurance,or a certifieJ
copy thereof(Sec.3800,Lab.CJ. /_ N
Policy No. any-& VIN 13^' l
Q ❑ led copy is hereby furnished. FIR SPRI K E T-
Z 2 ertifed copy is file with It my 'ns cede" division. MISC.- REFER TO ORD.
Applican L- Y
I- - PERMIT ISSUANCE 10.00 FLOOD ZON A. .
= - CERTIFICATE OF EXEMPTION FROM WORKERS'
Lu > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y[:] NY
CL O (This section need not be completed if the permit is for one TOTAL
::) 2 hundred dollars($100)or less.)
U O 1 Certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMAR
LL H mit is issued,I shall not employ any person in any In so as to
O L) became subject to the Workers'Compensutiun Laws of California. I G
Date Applicunl ALTER OR ADD TO MECH. 5.00
>- to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN C ECK
provisions of the Labor Cade, you must forthwith comply with FEE
U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10P00CF.NL) 4.00
IN
CONSTRUCTION LENDING AGENCY AIR HANDLGUNIT(OVER 10MC.F.M.) 6.00 SEISMIC FE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
file Performance of the work for which this permit is issued(Sec.
3097,Civ.0.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 0
Lender's Address
I certify that I have read this appliestinn and state that the above VENTILATION FAN (SINGLE) 4.00
infannulion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building const met inn, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
It
amhurize representatives of this city to enter upon the BOILER-COMP (Over t00,0008TU)SEE FEE SCH. MECHANICAL
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
mu y way accrue aga' stt Saad City in conce,�ue!{�e of the PERMIT ISSUANCE 10.00
gran go his en VIA, C+�� �-l�{Tr-t.4 MECH.CONT. -LIC.NO. MECH.
pyres ` �� TOTAL TOTAL
Slgnat of Applicant/Contractor Date
OFFICE COPY