11791 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 117 91
'Ola�l X111 -It V BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
rv4mE s(p$ OTV. ELECTRIC PERMIT FEE
Mfk. Olt PRONE O
CONTRACTORS
NA3 OUTLETS-SWITCHES-RECEP 10.00/1.00
ME
AkDA Ic.No. LIGHTING FIXTURES 10.00/1.00 1111f -
ADDRESSTORS y/S PPLIANCES-RESIDENTIAL 4.00
g�YS y ,
S ` PNONE y 0$ /0 PANELS 10.00 O GATE OF APPLICATION
ORcwTECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER I((✓ -
�n Op LIc.No. 9S4S� SIGNS TRANS. 3,00
moo ESS,ENO' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
2 Af3? $� w ✓ «r4,z,0JrSvAJ TEMP.METER OR POLE INS. 20.00
ADDRESSTB - MOTORS 2S !9 SEE FEE SCH.
SERVICE CHANGE 20.00 •/�`
woo LICENSED CON'T'RACTORS DECLARATION 7,^I A.�.
a u w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE OATS
(commencing with Section 7000)of Division 3 of the Business and .. BLDG. ELECT. PLG. MECH.
R ve z Professions Code,an my license is in full forcp•�1 aft I, 'y F} l x ❑ ❑ ❑
E, o;A m License Class Con Numberr� �-. �+ r
O Data�(` Con[redor- n�
¢ yLt
f 1_,. °11t BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION ;, , INFORMATION
o A° MISC.- - REFER TO ORD
F
g r 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
LLU. Law for the following reason.(Sec.7031.5,Businessman Professions pERM1T ISSUANCE 10.00 � �"
Fy0J Code:Any city or county which requires a permit to construct,alter,
8, La Q Improve,demolish,or repair any structure,prior to Its Issuance,also ELEG CONTR. LIC.N0. ELEC.
G w requires the applicant for such permit W file a signed statement that TOTAL 6 PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License c
Fza
Law(Chapter 9(commencing with Section 7000)of Division3oftlle EL(ECT/f./C,r4�
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
TE by any applicant for a permit subjects the applicant toa civil penalty - ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,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,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 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS=EA.SVSTEM•11NC.40UTL'ETS 6'.00
ments are not intended or offered for sale.IL however,the building
or improvement is sold within one year of completion, the owner- GAS•EASYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or in, . RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
Contracts for such projects with u contractor(,)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.far this WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ufconsent to self-insure' ZONING
or a certificam of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.38 0.Lab.C.). r,,
Policy No.G�79 onionty 5rA�r=^d
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T24
Z Z Certified copy is fled with the city inspection division. MISC.- ' REFER TO ORD.
O Ap Ireant Y ❑ N❑ Y'❑ N❑
~ rn PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
CC CERTIFICATEOF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Data-APPlicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex-
F,. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must,f..thwith comply with
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SIMC.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 HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 a
Lender's Address ELECTRIC .
I certify that I have read(his application and state(hat the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING,
ordinances and state 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 In enter upon the
above-mentioned property for inspection purposes, BOILER-COMP (OVBf 100,000 BTU)SEE FEE SCH. MECHANICAL
(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
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grand9C,ofthis permit.. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
$ignatureoff AAp_p-lieavi/Clontmcto Date
' OFFICE COPY