1100 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION vER ITN
BUILDINGBU APPLICATION & PERMIT 1 00
ADDRESS 11�
104x&4 NOCWIc.h N6 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S r .. PLAN CHECK VALIDATION
"7' N°NE QTY. �j- ELECTRIC PERMIT - rl. FEE,
•
4AlilQrn ♦ Myrna vj�u4o"C"PHONE .255.0385 [
clDRs
NAME OUTLETS-SWITCHES-RECEP m5.0011.00
NAME
I.C.NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS Q,QQ PLANCHECKFEE P.C.NO.
OR
ENGINEER
uc.NO, SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 X11141il
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION
¢is s~a 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
aG oi (commencing with Section 7000)of Division 3 of the Business and BLDG, ELECT. I PLG. MECH.
w i Professions Cole,and my license is in full force aril effect.
z o in - License Class Lic.Number pg}� CUPEKINQ
0 Z D Date Con[mcwt yJ,l!i
¢ g i ' �*BUILDING P,ERMIT41 ,11
¢ Q a¢, OWNER-BUILDER DECLARATION R ORD a+'Y(••�•�-J INFORMATION :>�.io.
X ;A m I hereby affirm that I am exempt from the Contractor's License MISC.- yq LUATION SIFT.
H• = 0 xt Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE6.00UZ
Code:Any city or county which requires a permit to construct.alter, (f7�-♦j
c a < O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NOPA ELEC.
i :O¢ requires the applicant for such permit to file a signed statement that l� TOTAL CIVp
w ow w he is licensed pursuant to the provisions of the Contractor's License .P - _, 95
WAW
Law(Chapter 9(commencing with Section 7000)ofDWisian 3 of theI'i;.}/ /L!O
c Business and Professions Code)or that he is exempt therefrom and OT.Y,: - a •P.LUMBING PERMIT,`-` ;IEEE`)[:
¢ H $ the basis for the alleged exemption.Any violation of5ection 7031.5 r+;a ' -.. _�:.i�•f -a. n:.-ku^....Oe .,. v' +'1 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 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. 4.00
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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-• GAS-EA.SYSTEM•7 INCA OUTLETS 4.00 ments are not intended or offered for sale.If,however,the budding
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM•OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RyES ��-I CON Pe Othsr
Prove 1.as ownerose
the.). INDUSTRIAL WASTE INTER. 20.00 IrJ l__I ❑ ❑ ❑
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the project La 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
o License Law does not apply
to tr owner of progeny who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 9.00
the Cont tors' License
cts Lwith ucontnctoAsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
reason LAi
1( Date WATER SYSTEM 4,00 ACC,DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofeomot to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy themcf(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. ' FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.• REFER TO ORD.
O Applicant Y❑ N❑ Y [3 N❑
� T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CL a LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PEG TOTAL U Y❑ N❑ Y❑ NE]
(This section need not be completed if the permit is for one
0 Z hundred dollars IS 100)or less.) �;r vS * ^n tJn u a x - vc+� g- Y a +s' a« nl
U O 1 certify Thal in the performance of the work for which this per a ¢ 'n- +{v r$r.11 ry uR'u:. j- � .ZVi b f i SUMMARV'',`7�
OTY MECHANICAL PERMITC, ��s sc FEE- ._ .s.. ... s-. 's.A
LL H mit is issued,I shall not employ any person in any manner so as to s.
U become subject to the Workers'Com enation Laws of California.
0 w Date 1 Applicant v BUILDING -
a ALTER OR ADD TO MECH. 4.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F., Z emption,you should become subject to the Worker'Compensation APPLIANCE 4.00 PLAN CHECKS '
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.FM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 6'd
Lender i Address ELECTRIC
1 certify that I have read this application andStam that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
• odinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon lha BOILER•COMP(Over100,0o0BTU)SEEFEESCH, MECHANICAL
above-mentioned property for inspection purpoxs.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3,00 CONST.TAX
may in any way accrue against said City in consequence of the
LE
granting of this permit. MECH.CONT. LIC.NO. MECH. 'y '••,..s ^ te
TOTAL h :fllnr -
712iira� �itBexd 3y;TOTAI + �Y3
SignolrAPP licxntlComractor Uatere'z
OFFICE COPY