6652 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 6652
aoOREsy�
24411 MAXIAJ6ry BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow EN'S PLAN CHECK VALIDATION
rvamE CITY] ELECTRIC PERMIT FEE
Ahba PhPHONE
CONTRACTOR VSOUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Llc.rvo. V9fLIGHTING FIXTURES 5.00/1.00
CONTRACTORS
Ai (�
- APPLIANCES-RESIDENTIAL 4.00
UIJO GESS _
ONE PANELS 5.00 DATE OF APPLICATION
A C TELT SIGNS 6.00 PLAN CHECK PEE P.C.NO.
OR
ENGINEER
uc,NO SIGNS TRANS. 3.00
ARCH.GR ENG
AOnHESs . SPECIAL CIRCUIT 6,00 PER IT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 /
AMOTORS SEE FEE SCH.
ADORE SS
aDORE
SERVICE CHANGE 10.00
FOO LICENSED CONTRACTORS UECLARA'I'ION
¢v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N < i (cummenemg with Section 7000)of Division 3 of the Business and LO ELECT. PLG. MECH.
H m z Professions Code�yT}W yyt�nse is in full forcL.gryl{ffjjcc�-/�
z o m - Vale Clasz_a,,,�`! Lia Number j� ❑ ❑ ❑
o� �_w D:Im cahhtmaar F / /�A l 7-2 - B
Q y 2 J
¢ ¢ w a -BUILDER DECLARATION BUILDING,PERMIT,;iv,#-. y
K O a ca MISC.- REFER TO OR
INFORNIATION�,s
wm I hereby affirm that I am exempt from the Contractor's License
.. o j Law lirr the following reason.fSec.]OJ LS.Business and Professions PERMIT ISSUANCE VALUATION S/FT.
L" - Code:Any city or county which requiresa permit construct,alter, 6.00 /f�a�s0.�
R < 0 improve,demolish,or repair any structure,prior LLt its issuance,also ELEC.CONTE. LIC.NO. ELEC. /vyl/U /
-O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT 0
a w m" he is licensed pursuant to the provisions of the Conlrmtor's License
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthefiteU✓
5 4 ao Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ;'n by any applicant lar a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500)J:
❑ I,as owner of tire properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensalion,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 so.FT.FLOOH AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
f mem,are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RE IND CON PS Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of lire property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL ND.
and Professions Code:'I'he Contractors 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 aontractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
le.lon
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00 -
I hereby affirm that I have a certificate of Consent to self-insurx'• ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insu nee,or a certified
copy Iher ec 3 0,hab,Cy
Policy A, �,Pompany-Tpt�.
Q ❑ Cert, 'd copy i,hereby lunusIWI. r FIRE SPRINK ENERGY T 24
Z z Cl Cc iq fuF� , rod ,yim t • r inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
O Applicm"L
CC T CISRTIFICATI.( 'XIiMPPION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LD > COMPIiNSATION INSURANCE PLG.CONTR. ❑c.NO. PLG.
CL O (Phis section need not he annpldt d if the pertnil is lint one TOTAL V❑ N❑ V❑ N❑
D 2 hundred dollar,($100)or less.)
U OI certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY'S
LL F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers''Compensation Laws of California. BUILDING 5
Date Applicant ALTER OR ADD TO MECH. 4.00
} N NO'na 'TO APPI.ICAN'f: If,alter making this Certificalc.of Ex-
F, Z engrtum.you should become subjaet m the Workers'Compatsution APPLIANCE 4.00 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.) 3.00
CONS[RUCDON LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency forEXHAUST HOOD (WITH DUCT) 2.00
Ili, performance of the work for whim this permit is issued(Sec. HEATING UNIT TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.CJ.
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that[have read this application and state that the above V ENTILATION FAN (SINGLE) 3.00
t iumunation is mrrcet. I agree m comply with all city and county BOILER-COMP(3 H.P.or 100,000B.T.U.) 4.00 PLUMBING
:ordimmcas and state laws relating to building eonslruclion, and
crcby autwrve representatives of this city to enter upon the BOILER-COMP (Over IOO,000BTUISEE FEESCH. MECHANICAL
ubovementioned property for inspection purposes.
(We) agree to salve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
aha in any way accrue a•einst said City in cnnsequcncexol the PERMIT ISSUANCE 3.00
g 11 hf Wi.+. I'll . MECH.CONT, LIC.NO. MECH.
/
TOTAL TOTAL
SigualureofA ant/C ractor P Da e tl
OFFICE COPY