11072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11072
ADDRESS loK✓ _ ELS_.. BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
r� rvnME - DTV. ELECTRIC PERMIT FEE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
1�M `E \ \,rCWtnt.7 LIC.rvo. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS f) APP LI ANC ES-RESIDENTIAL 4.00
A RE55 .:JJCLJJ
HON PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
AR CH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS A
SERVICE CHANGE 20.00
woo LICENSIi D CONTRACTORS DECLARATION
S`u u I hereby affirm that 1 tun licensed under provisions of Chapter 9 ISSUANCE ATE
h Q H (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N z Professions Cod nd�yy}�e'-is in full f c
2 O w - Liccl C Lia Num ❑ ❑ ❑
O 2 F w Date Contractor _ -
a x f BUILDING PERMIT
a w ¢ OWNER-BUILDER DECLARATION INFORMATION
O
w LL H 1 hereby alfinREFER TO ORD
n that I inn exempt from the Contractor's License MISC.- VALUATION $/FT.
F I, Oa Law for the following reason.(Sec.7031.$,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
QQ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO, ELEC.
aa
D R reclulres the applicant for such permit to IIIe a signed statement that TOTAL pERMIT O
A w m" he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencingwith Section 7000)o(Division 3ofthe
Business and Professions Code)or that be is exempt therefrom and OTV. PLUMBING PERMIT FEE
R H p the basis for the alleged exemption.Any violation of Section 703 L$ STORIES TYPE CONSTR.
n; m by any applicant for a permit subjects the applicant too eivilpenalty ALTER-DRAIN& VENT-WATER'1EA.) 5.00
of not more than five hundred dollars($500).1:
C, 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who I)oilds or improves lllereon,and who doe,Snell work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.It,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUIING USE
builder will have the burden of proving that he did not build or im- LDRES IND CON PS Omer
Prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
Cl I,as owner of the property,am exclusively contracting with
linewd contractors to construct lite project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 HSSESSOHSPAHCELNO.
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-OV ER 5 1EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ l amexempt un der Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPP.NSATION DECLARAT ION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. 20NwG ENG.SITE NO.
or a certificate of WorIs Compsalion Insu'nee,or a cert ifiud _
copythL�sgqs.��(� QQQQL01..{{yyIn� (�
Policy NO471W611idp_' '.B F�
Q ��❑//Certified copy ishemb I mished FIRE SPRINK ENERGY T 24
Z Z XCe a s file a 't nspectioo division.
ApplicantJ/_F'SLl �' MISC.- REFER TO ORD. y N❑ y N❑
� PERMIT ISSUANCE 10.00 FLooD ZONE A.L.U.c.
LU CFiRTIF'ICATEO BION ION FROM WORK BBS'
W >_ COMPIiNSA'I'ION INSURANCE PLG.CONTE. LIC.NO. PLG.
o (This section read not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ IN❑
Z hundred dollars($100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H Init is issued, 1 shall not employ any person in any planner so as to
O w becomesubjecttothe Workers'Compensation Laws ofCalifornia. FELECT
Uam Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE'1'0 APPLICANT: II',after making this Certificate of Ex-
r Z einplion,you should become subject to the Workers'Compensation APPLIANCE 5.00
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO}OAf1DG4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER-ld DC.EM.) 6.00
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH U T nL41#1
the performance of the work for which this permit is issued(Sec. HEATING UNIT(T0 100,0 .T.U.) 8.00
3097,Civ.CJ-
Leader'sName HEATING UNIT(OVER 100,000 B.T.U.)9.50 xm
Lenders Address
• 1 certify that 1 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 BOILER-COMP13 H.P.or 100,000 B.T.U.( 6.00 PLUMBING
ordinances and slate 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 inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- R FER T0 ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 110.00 CONST.TAX
may in any way accrue agai st said City in consequence f the Iia
8 ane this p r t ,(� MeehNT. LI O. TDTAL I(}t yl v TOTAL
S t reef Applicant omramor Uule a UU 1 `11`1tFF-+lr^311+,Mr F_3I xU vv�
OFFICE COPY