3118 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT.PEN ONLY
BUILDING PROJECT IDENTIFICATION
soaolNr,. APPLICATION & PERMIT
ADDRESS. v
IQs ING-ELECTRICAL-PLUMBING-MECHANICAL 8
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE'
o r i n Ke, PHONEZS - 131
corvTRacrDRs C_4p -;),oOUTLETS-SWITCH
ES-RECEP 5.00/1.00
La$' LIC.ND. LIGHTING FIXTURES - 5.00/1.00
ADDIRE crDRs- PPLIANCES-RESIDENTIAL 4.00 -
ADDflE53
'r PRONE - PANELS - 5.00 DATE OF APPLICATION
ARCHITECT - - - PLAN CHECK FEE P.C.NO.
DR SIGNS 6.00
ENGINEER--_ LIC.NO SIGNS TRANS. 3.00
ARCH.OR
ADDRESS ENG. SPECIAL CIRCUIT '5.00 PERMIT„VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 n .
APPucANTS
ADDRMOTORS SEE FEE SCH. 492�[�/
ESSc
5 �- �C) SERVICE CHANGE 10.00 o p ?
Doo LICENSED CONTRACTORS DECLARATION
a u w I hereby affirm that I am licensed under provisionsrf Chapter 9 - ISSUANCE DATE '
F (commencing with Section 7000)of Division 3 of the Business and
y ¢ BLDG. ELECT. PLG. MECH.
r too
w i Professions Code,`d y lixnL is in full for nffte� ,
Z,o m - Datense�.C-lasagl V Lin.Number .77JJ - 11
4 H H w Dnre Contractor
a se Y .+ BUILDING PERMIT
rt ¢ ¢ OWNER-BUILDER DECLARATION '
o d D MISC.- REFER TO ORD INFORMATION
K
; LL y 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
FUD¢ Law for the following reason.(Set.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Anycity or county which requires a permit to construct,alter,
2 ¢ a p, improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. TEL ETC ,
i w a u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Fir
Law(Chapter 9(commencing with Section 7000)of.Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 by any applicant fora permit subjects tire applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.0
of not more than five hundred dollars(5500).): - -
❑- [,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEV ICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00
SQ.FT,FLoofl AREA TOTAL ACREAGE
himself or through his own employees,fors,Provided that such improve-
m nts usello not intended oroffereoyees,Provided
ed fluahoweveDshc building ,GAS-EA.SV$TEM-11NC.4OUTLETS 4,00
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-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. RES IND CON PB Other
O 20.00 I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law tines 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 a contractors)licensed Pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.GATE ACD.FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirns that I have a certificate of consent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
cop
Py�her f ec. .((O�j,3h. .1,�-7 dy'/.
0 1❑' or
Certified co y lss hereehby furnished. /J FIRE SPRINK ENERGY T.24
Z Z Certified copy is filed with the city inspectio divinon. MISC. REFER TO ORD.
P: O PPllcan[�T � �J.I�srn.ss./J_�-�1t I Y ❑ N❑ v ❑ N❑
CC LO CERTIFICATEOF EEXXEEMM'PTIIdjNrPROM WORKERS' PERMIT ISSUANCE 6.00 �� -FLOOD ZONE A1.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
0' a (This section need not be completed if the permit is for one - TOTAL t Y❑ N❑ Y ❑ N❑
D Z hundred dollars(S 100)or less,)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL )- mit is issued,I shall not employ any person in any manner so as to � a
O W become subjecttothe Workers'Compensation Laws of California. ,
Date Applicant - BUILDING
CL ALTER OR ADD TO MECH. 4.00
} N N prion,TO APPLICANT: If,after making this Certificate of Ex-
F Z empuon,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io the
or Labor Code, you deemed
revoke comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10A30C.F.M.) 5.00 .SEISMIC FEE
I hereby affirm that there is u construction coding agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is!%sued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00 �-
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with ell city and county PLUMBING
ordinances end state laws relating to building co city
andnn, anA BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize represenlalives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 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 PERMIT ISSUANCE 3.00 CONST.TAX
min any ny way accrue against said City in consequence of the
gran Ing of t s permit MECH.CONT. - LIC.NO. MECH.
?L ,�eQnf�6 TOTAL �7 dv TOTAL
ore of Applican/Co ractor Date / 2-
OFFICE CQPY