11335 APPLICANT TO•FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
euILDINGO/� / ; /er , APPLICATION U PERMIT 11335
f 0 LmNs
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNE S ` - PLAN CHECK VALIDATION
NAME QTY: ELECTRIC PERMIT FEE
Pber.:
PHONE
""MTRAcrofls p TnG UTLETS-SWITCHES-RECEP 10.00/1.00
•O� hS�C }NO, LIGHTING FIXTURES 10,00/1.00
CONTRACTOR'S �/O APPLIANCES-RESIDENTIAL' 4.00
AD RREESS� //� JAI, ! "
�%"/ 5 rF1ll -eu Fes' , & OI) PANELS - 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMPI 2000 PLAN CHECK FEE P.D.NO.
OR .
ENGINEER ,
LIC.No. SIGNS TRANS. 3.00
ARC
H.OR ENG. PERMIT VALIDATION
AooREss SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 V F���
w o o LICENSED CONTRACTORS DECLARATION - O
a v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN E°ATE
w a$ (commencing with Section 7000)of Division 3 of the Business and ELECT. PLG. MECH.
rofessions Code�I d my license is in full to a e(f
Z o m- icense Class_[]'' Lic.Number Ep "y - - • ❑ ❑
-o Z F o Date.��,l� ConrmctorS�+ /hS ON 1 ' I
Y s - JV BUILDING PERMIT
Ir rt w OWNER-BUILUF.R DECLARATION 1 RMATION
" w ;n I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD ON S/FT.
LL a < Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE- 10.00 _11
� - w Code:Any city orcounty which requires a permit to construct,alter,
0 improve ,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. I LIC.NO. ELEC.
i E D u requires the applicant for such permit to file a signed Statement that TOTAL PERMIT O
,Kam,A he is licensed pursuant to the provisions of the Contractor's License r,�c OCix('� OOF•z�
rz>
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i c Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE - �LZ
a:f the basis for the alleged exemption.Any viola l ion of Sect ion 7031.5 STORIES TYPE CONSTR.
a;� by any applicant for a permit subjects the applicant Ina civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of nol more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE : 4.00
[],air sole compensation,will do the work,and the Structure is not OCC.GROUP RES.UNITS
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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale,If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
�i builder will have the burden of proving that he did not build or im-
BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
. .
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ 1 ❑ ❑
licensed contractors to construct The project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
Per
Owner Date WATER SYSTEM 5.00
ACC.DATE. ACC.FILE N0.
WORKERTCOMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of Consent mself-insure,-74 ZONING
ora cthertificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy elect(See,3800,Lab.C.).
Policy No. Company
O ❑ Certified copy iS hereby fur fished. FIRE BPRINK ENERGY T2
Z y� Cartified�wp is Y th the aitlnSFeclion division, MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
•O Arplirurt-/�- V N V N
- PERMIT ISSUANCE 10.00
2 - CI:RTII°KATE OF EXE ION FROM WORKERS' FLOOD ZONE A.L.U.C.
LU > 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❑
D Z hundred dollars($100)or less.)
V O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. H mit is issued,1 shall nro employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. q
O ED Date Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f.. Z emption,you should become subject to the Workers'Compemation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 110AWC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lender's Name
Lender's Address HEATI NO UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I cerlify that I 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 PLUMBING
(ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP love,100,0006TUI SEE FEESCH. 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, dgments, costs and expenses which CONST.TAX
may in a way ace a a- s1 Said City in consequence of The PERMIT ISSUANCE 10.00
granting p s. MECH.CONT. LIC.NO. MECH.
TOTAL 93 3
Sign of
plrctWUog0cfor Date
OFFICE COPY