11620 t .APP, SICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION - PERMIT Numsen
V 'A0 RE APPLICATION & PERMIT " 11620
r ADDRESS l)) BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
n•SI-� �U - •
NAMEOWNER'S 1�'J' PLAN CHECK VALIDATION
lr 3a/gt%st Cit ave!= QTY. ELECTRIC PERMIT FEE
1 0 K V PHONE
CONTRACTORSUTLETS-SWITCHES-PIECED 10.0 1.00
COME
ASE.No.
C LIGHTING FIXTURES 10,00/1.00
CONTRACTORsPPLIANCES-RESIDENTIAL 4.00 s
ADDRESS SJs
r aE•`t.,.�,16 PANELS 10.00 DATE OF APPLICATION
✓✓H PHONE
ARCHITECT - PANELS (OVER 200 AMP) 20.00 •PLAN CHECK FEE' P.C.NO.
OR
O
ENGINEER
uc.NO, SIGNS TRANS. 3.00
AARCH.DR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP TEMP.METER OR POLE INS: 20.00
A - MOTORS,. SEE FEE SCH.
ADDDRESSDRESS
' SE ICE CHANGE 20.00 pb
woo LICENSED CONTRACTORS DECLARATION IG r
<u I hereby affirm that I am licensed under provisions of Chapter 9 - r ISSU NC DATE
z (commencing with Section 7000)of Division 3 of the Business and G.^ L . - PLG. MECH.
~ F Professions Code nd ey Innis is in full in efWsT I / �/}t, .❑ ❑
2 0 2 - License Class Lia Number S u ❑
0 z 0 Date Contractor -
Q y E O 4L G PERMIT
M Is: w Q OWNER-BUILDER DECLARATION UI " INFORMATION
- n 0 a MISC.- REFER TO ORD
wg a I hereby affirm that 1 am exempt from lite Contractor's License
u0Q Law for the followingmason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 10.00 VALUATION $/FT.
F W 0J Code:Any city or county which requires a permit to construct,alter,
Q v, Q O improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant,for such permit to file a signed statement that TOTAL PERMIT TO
Ew$w he is licensed pursuant to the provisions of the Contractor's License
Fi> Law(Chapter 9(Commencing with Section 7000)of Division 3'ofthe AIG I/E" iQ.,VoTV
4 c Business and Professions Code)or that he is exempt therefrom and aTY. PLUMBING PERMIT FEE
1- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
as by any applicant for a permit subjects theapplicant to o civil penalty ALTER-DRAIN -WATER (EA.) 5.00
"
of not more than free hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their 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
1 „v property who builds or improves thereon,and who does such work FIXTURES-PER TRAP '5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments
mprove-
memsamnotintended 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- GAS--EA.SYSTEM-OVER 4(EA.) 2.00
•tl�.xl builder will have the burden of proving that he did not build or im- BUILDING USE
t RES IND CON Pg Diner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
El 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 ASSESSORS PARCEL NO.
end 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 forsuch projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. _ TRACT NO. PARCEL NO.
0 I am exempt under Sec. ,B SPC'for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
I WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy
Policythere ( .36
ec00,Lab.C.). ('x _ .,! _E0�v
No. Company_Zl=
0 ❑ Cerli ' op is her by furors FIRE SPRINK ENERGY T-24
Z Z ❑ Certif copy i r wit th city mspec on division. MISC.- REFER TO ORD.
p Applicant Y ❑ N❑ Y ❑ N❑
H -y PERMIT ISSUANCE 70.00 FLOOD ZONE A.L.u.c.
� C TI FICATE OP EXEMPTION F O WORKERS'
W ___._OINSURANCE PLG.CONTR. LIC.NO. PLG.
O_ a (This section need not be completed if the permit is for one TOTAL V C] N❑ Y C1 N❑
LD Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Calilornia. p.G
U i Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT:If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of Ilse Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 104000.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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
"Askinformation is correct.1 agree to comply with all city and county - PLUMBING
ordinances end stale laws relating to building constfuclion, and BOILER-CAMP 13 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
r
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,j ents, costs and expenses which - CONST.TAX
may in any cme agar sl sit City in consequen c of the PERMIT ISSUANCE 10.00
granting s p i MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
Si ature oFApplic-na/C.ntractior le C
OFFICE COPY
ADDITIONAL PEEMLT FEES
BUILDING PROJECT IDENTIFICATION VALUATION
ADMEW q�
ADDRQS'�5�/�(GC� VICt-
' OWNERS
FEE SUMMppY
coxw•croRs - BUILDING Sa`
N•ME
SONTRACiOP'S- - PLAN CHECK I &
•ooREss FEE
vxoxE _ SEISMIC FEE
OTY. ELECTRIC PERMIT -'FEE
UTLETS-SWITCHES-RECEP. - ELECTRIC
LIGHTING FIXTURES
PPLIANCES-RESIDENTIAL _ - MBING
PANELS: .. CHANICA.
SIGNS
SIGNS TRANS. TOTAL 7317
' SPECIAL CIRCUIT
EMP.METER OR POLE INS. REH vquDATIDN
MOTORS SEE FEE SCH. _
0' SERVICE.CHANGE
! .
.Z
y To a� 5`�E�'
--LU OTY. PLUMBING PERMIT. - - YFEE - ISSUANCEDATE - -
-a p BLDG. ELECT. PLG. MECH.
_� 2 ALTER-DRAIN&VENT-WATER(EA.) ❑ ❑ ❑ ❑
V O BACK FLOW PROTECT.DEVICE -
U_ U
Q w - DRAWS-FLOOR.ROOF,AREA,COND_- "�GO.U7� cSO
aU@i
FIXTURES-PER TRAP '
F GAS-EA-SYSTEM-11NC.4 OUTLETS -
V GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B. -
LAWN SPRINKLERS-OVER 5(EA.I•-
SEWER-SANITARY-STORM EA.2 fU
WATER HEATER INVENT
WATER SYSTEM
WATER TREATING EQUIP. - - -
'- OTY MECHANICAL PERMIT FEE' -
-- - ALTER OR ADD TO MECH. - - -- - -
APPLIANCE -
_ AIR HANDLING UNIT(TO 10AMC.F,M)
AIRHANDLWG UNIT(OVER IOAODGF.M) -
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.).
HEATING UNIT(OVER 100.000B.T.U.) -
VENTILATION FAN(SINGLE) -
BOILER-CONp(3 H.P.or 100,000 B.T.U.) '
BOI LER-COMP,1p e,11,011 BTU)SEE FEE SCH.
TOTAL