10997 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 10997 O^9 r^n
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 19
OWNE 'S PLAN CHECK VALIDATION
2),S 'I - QTY. ELECTRIC PERMIT FEE -
5ou1tQt PHONE O-\
CONTRACTORSUTLETS-.SWITCHES-RECEP 10.00/1.00
NAME C1Q-dl UDC"0. CA'
Etc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTQR''s PPLIANCES-RESIDENTIAL 4:00 -
ADDRESSY.f19pG1aI -
�1 �'1 PHONE PANELS 10.00 DATE OF APPLICATION
O.NO.
O
ARCHITECT PANELS IOV ER 200 AMPI 20.00 PLAN CHECK FEE P.
ENRGINEER
UC.NO. SIGNS TRANS. 3.00
ARCH OR ENG. - - 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
21P
EMP.METER OR POLE INS. 20.00APPLICA
-^�•
06ADDRESSTa laO� IA UD1-O•Iyy '� _ MOTORS SEE FEE SCH. jj ` •\
F S SERVICE CHANGE 20.00 _ (�`\00//V/
L e S
w o o LICENSED CONTRACTORS DECLARATION Of G\\Q
a v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
re
w<H (Commencing with Section 7000)of Division 3 of the Business and
h - BLDG. ELECT. PLG. MECH.
F z Professions Codes�and��my license is in full fo cc and"A feel. - ❑
Zo m - License Class�_�Lp_Lie.Numb ❑ ❑
o Z H Date Con[raeto q_y.,�'b WALK ���u'�
P , 2 IE]ry1 b,-�1C(, BUILDING PERMIT
¢ a w ¢ OWNER-BUILD DECLARATION Q INFORMATION
a0 MISC.- REFER TO ORD
w3 LL m I hereby affirm that I am exempt from the Contractor's License VALUATION S/f T.
ac o¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 r
t - Code:Any city or county whichrequiresapermit toconslruct alter,
¢Q o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such permit to file o signed statement Ghat TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License Oi p
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /"
I i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Seclion7031.5 STORIES TYPE CONSTR.
n3 - by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(35001.):
❑ I,as owner of lite 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 ro as owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that Such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11N C.4 OUTL ETS 6.00
or improvemmnt is sold within one year DIcompletion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will havethe burden of proving that he did not build or iin- RES IND CON PB Other
prove for purpose ofsale.). - INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the properly,am ezchisively contracting with
licensed contractors to construct the project(See.7044,Business LAWN.SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Cunlractur's License Law does not apply
to an owner of property who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
• contracts for such projects with n contractor(,)licensed parsuonl to SEWER-SANITAR V-STORM EA.200ftI10.00 7.
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam Cxempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner 'Date WATER SYSTEM 5.00 ,ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm Glat 1 have a certificate of Consent to sill-insum. ZONING ENG.SITE NO,
or a certificate of workers'Compensation Insurance,or a certified
copy theref Se 00,L.b.C.� .T.
Policy No. Company -
O ❑ Certiliedc sImrtby rn)Ehed. t / _ FIRE SPRINK ENERGY T-24
Z 2 'SYt�rf ie is It �i0 the,<it an lecli J`Asion MISC.- - REFER TO ORD. v ❑ N❑ Y ❑ rv❑
Applicant ?2t-
F PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
M - CERTIFICATEOr IiXEMPI'ION PROM WORKERS' -
lU >_ COMPENSATION INSURANCE PLG.CONTR. Q_C LIC.NO.M� PLG.
a0 TOTAL V❑ N❑ Y ❑ N❑
(This section need not be completed if the permit is for one '
::) Z hundred dollar,(S100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. 'BUILDING
w Dare ' Applicant ALTER OR ADD TO MECH. 5.00
>_ ED NO"I'ICI: 'f0 APPLICANT: II,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deClned revoked. AIR HANDLING UNIT(TO 10PWC.F.M.) 4.00
CONS'I'RUC'f10N LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm 111.1 there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the prd'ounarce of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Add..Lender's HEAT[NG UN IT(&V ER 100,000 B.T.U.)9.50 ELECTRIC
-, I certily that'I-have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
�l
information ncorrect. 1 agree ticomply ildingall cCity and county BOILER-COUP(3 H.P.or 100,000B.T.U.)-6.00 PLUMBING -
infor nee, and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,00013TU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We)-agree to save, indemnify and keep harmless the City or MISC.'- REFER TO ORD. ,
Cupertino a st Iiabiliti ,judgments, costs and CX
penses which CONST.TAX
may in a ay ac a against wiJ-City in conuyuen<c of the PERMIT ISSUANCE .10.00 ,
grnorm is per MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si at rc of pPlicant Conlroctor Uate e
OFFICE COPY
ti f