10051 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT IDENTIFICATION PERMIT NUMBER
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ADRESSILDIN APPLICATION & PERMIT 10051
`1
202C12N V F_ 3 , BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S ��I�� PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• 5 PRONE �4 ? A i D
NOMERLLA�JcroRs nn OUTLETS-SWITCHES-RECEP 10.00/1.00
J'T�711_ uc.NO.�4u�g1 LIGHTING FIXTURES 1000/1.00 AUG- 5 199
ADDRESS
CONTRACTORS APPLIANCES 4.00
ADDRESS Ar,1vk ,, may- '
3� �1�Y�v1 ONE PANELS 1D.00PI v rDATE FAPPUCASION
ARCHITECT v,PLAN' H C ILL P.C.NO.
DR PANELS (OVER 200 AMP) 20.00 ___
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.08 DDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
APPLICANSS MOTORS SEE FEE SCH.
ADDRESS
E
32G P"4Kla -9Mb PCO 9� k SERVICE CHANGE 20.00
ww o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �(�I
< U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w< m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Cod and my license is in full force IILt feet ❑ ❑ ❑
0 o o - License C�I'�sy Co Numb-r h
o 0 F LeDatc_C I" Lie.N cob p����J
¢ y s T"^- BUILDING PERMIT
¢¢w a
OWNER-BUILDER DECLARATION INFORMATION
dodo MISC.- REFER TO ORD
w LL H I hereby al❑rm that I am exempt from the Contractor's License VALUATION E/FT..
F u o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code.Any city or co only which requires a permit to construct,:Jtee
2 a,Q improve,demolish,or repair uny structure,prior to its isean",also ELEC.CONTR. LIC.NO. ELEC.
O
a, requires the applicant]or such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
F z
to
Law(Chapter 9(commencing with Section 7000)of Division 3 office
F i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
,w T by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mor,than five Imndred dollars(S500)J:
❑ 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,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds 9r 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 are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
I or improvement is sold within one year of completion, - . -OVER 4 (EA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Oma,
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors ID construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSE55ORSPARCEL NO.
and Pwfasions Code:The Contractor's License Law does riot 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&['.(:.tie this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby afliun that I hove certificate of consent to sell=insure, ZONING
or a certificate of Workers''Compensation pention Insuronce,or a cerblied ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O ❑ Certifi p hereby furnished. FIRE SPRINK ENERGY T 24
Z ZCertin a ith tic 't ' s t,In pippvision, MISC.- REFER TO ORD.
V
U P,1 ant SId- Jam( C] N E] Y ❑ No
Fonl PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
j ' 11 WATF OIr EXEION PROM WORKIi RS'
lJJ _ '. SATIO INSURANCE PLG.CONTR. LIC.NO, PLG. V[:] N❑ V ❑ NE]
0 ('Phis section need not be completed it the'permit is for one TOTAL
Z:) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per, OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
y Dam ApplicantALTER OR ADD TO MECH. 500 BUILDING
} m NOTICE: TO APPLICANT': ll',after making this Certificate of Ex-
.
F Z empfion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tine Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO IO=C-F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hemhy affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work lot which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B,T.U.19.50 ELECTRIC
Lender's Address
I certify that l have read this application and.cule that the above VENTILATION FAN (SINGLE) 4,00
information n correct I agree to comply with ulc city and county PLUMBING
ordinances and slam laws relating to building construction, and BOILER-COMP13 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city fO emer upon ole 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.- REFER TO ORD.
Cupertino against liabilities,judgments,costs andexpenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting 9fthis permit MECH.CONT. LIC.NO. MECH.
TOTAL /
Signature of ApplicanljContractor Date r-"• "� `�" `�'1�-1 �I 1`✓'1 -{� _ '
OFFICE COPY
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