10013 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING /� APPLICATION & PERMIT 10 013
z? /�./ ', BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
�J l/li '• -1�1 - S 1i1 t", "'A4, Y,� r N ^,-. PLAN CHECK VALIDATION
/ OTY. - ELECTRIC PERMIT A, r tG FEE
O `•
PHs3s)__ r s,
• CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NPM _
�• ( I.M.I4011677 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
0 r�G - F�mNCL PHONE O PANELS 10,00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.L.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDR.SS ENG. SPECIAL CIRCUIT 5,00 P�MIT VALIDATION
ADDRESS w�
ZIP EMP. METER OR POLE INS. 20.00 �"�l�
APPLICANTS MOTORS SEE FEE SCH. NOV
ADDRESS - 51985
• SERVICE CHANGE 20.00 y,'
TEMP.POLE 30.00 `' Of CU 1�1pf�
O o o LICENSED CONTRACTORS DECLARATION I f1n.a
Is u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE 0E
w<m ommencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 w i License
Cl Cod and y license is in full forceforce an(L ❑ ❑ ❑
o ia• License Class Lia Number
� Date Contractor
~ J
E J BUILDING P RMIT:1,','-i�'.-"v"7
¢ w ¢ OWNER-BUILDER DECLARATION '..`�:�^INFORM TION71„-J'x-,
LL N Li
I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION
u04 Law for the following reason,(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
J Code:Any city or county which requiresa permit to construct.alter,
c a Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
O Q requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m" he is licensed pursuant to the provisions of the Contractors License - /
i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe r �/f//J��J
r Business and Professions Code)or that he is exempt therefrom and OTY -4 PLUMBING PERMIT°I+ �• FEE$. ei✓�
_ a
¢ $ the basis for the alleged exemption.Any violation of Section 7031 5 =:f.W'c, f:!r 1c. ° y.' .c.?� N'('- tf.i ' STORIES TYPE CONSTR.
ii - by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,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-FLOOR,ROOF,AREAv COND. 5.00
Code:The Contractors 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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
-�'d ments are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-I 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 int- 2-EA.SYSTEM-OVER 4(EA.) 2.00 RE IND ILOCON USE
builderOsher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
0 1,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 ASSESSOR5 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 contractor(,)licensed pursuant to
SEWER-SANITARY-STORM EA.200ft/10.0 TRACT NO. PARCEL NO.
the Contractor's License Law.
O lam exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.PILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING or a certificate of Workers'Compensation I surance,ora certified ENG.SITE NO.
Copy'h115- 1
e, Re 00 I�,�Ah.C.L 1� _/,/PaM
Policy No!�L'J(1C"any ��, �J
O I ❑ C ified Copy is hereby furnished. r FIRE SPRINK ENERGY T-24
Z Z Ceru I co d w h e ci inspection division. MISC.- REFER TO ORD.
O Applicant rs Y ❑ N❑ Y ❑ rv❑
2N CERTIFICATE OF EXEMPTION FROM WORK ERS' PERMIT ISSUANCE 10.00 Q- FLOODZONE A.L.U.C.
W - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be Completed if the permit is for one TOTAL ' Y❑ N❑ Y❑ N❑
=) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL'PERMIT - FEE _ ..•FEE SUMMARVI_m"->i;a+'e
F mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U i Date Applicant ALTER OR ADD TO MECH.y 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of -x-.
F_ ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U such provisions or this r visions of the bpp`rmit shall be deeou med revokted`amply with
AIR HANDLING UNIT(TO IO=C.F,M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.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. HEATING UNIT(T0 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lenders Name HEATI NG UN IT(OVER 100,000 B.T.U,)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 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-mentioned property for inspection purposes.
(We) agree t0 save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities.judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granll0g flit rmiL 1 MECH.CONT. LIC.NO, MECH. - -•',' •• -
TOTAL : TOTAL T'
Signature o(Applicant/Cnnlracmr Date I I _E
OFFICE COPY