16856 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON .PERMIT NUMBER
a�021 o'oae"s APPLICATION & PERMITnOZSI PA&L T LACE- BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 16856
OWNER'S PLAN CHECK VALIDATION
NAME
s DTV. ELECTRIC PERMIT FEE
.w L`T U u An 1
D PHONE (l
CONTACTORS '3 UTLETS-SWITCHES-RECEP 10.00/1.00
OwQlaz, LIC,NO. LIGHTING FIXTURES 10.00/1.00 pd
ADDRES$ACTons PPLIANCES-RESIDENTIAL 4.00
ADORE
I PHONE PANELS 10.00 DATE OF APPLICATION ,1
ARCruTECTPLAN CHECK FEE I P_C ANO.
OR ,S-ig✓E �{PP�7 PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.Na.0 IZ Z'!3 SIGNS TRANS. 3.00
ADDRESR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
pe_ J,,IP`is"Izl TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERV) E 21.
o ¢ i
o o LICENSED CON]RA
DECLARATION �_
Eta y I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n< A (conimencing with Seeded 7000)of Division 3 0l the Business and - BLDG. ELECT. PLG. MECH.
0 y z License Professions Code,anA my license is in full force and effect.
z o r - License Class Con Nunfluractor r DATE tr
Q � -� Da1c Contractor
< y E _ BUILDING PERMIT
F R w OWNIi R-BUILUBR DECLARATION INFORMATION
F
;LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u. D e Law for the following reason.(Sec 7031.5,Busine,sand Professions PERMIT ISSUANCE 10.00 V� VALUATIO ('�je SIFT.
�,w J Code:Any city or county which requires pend It to construct, Its,,
rtto s- 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC,NO. ELEC.
O LL requires the applicant for such permit to flit,a signed statement that TOTAL a,7 a �D PERMIT TO
A w he is licensed pursuant to the provisions of the Contractor's License //��
F z Q
Law(Chapter 9(conmlencing with Section 7000)of Division 3 of t he VOA
Business and Professions Code)or that he is exenpt iherctium and QTV. PLUMBING PERMIT FEE 1d PLUMBING PERMIT FEE VV
¢ o _ the basis for the alleged exemption.Any violation of SvclPm 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00 E9(�
of no}mon titan . .
n five hundred dollars -
Ry to ns 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 It), ale (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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 .fad SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such u improve- Ti�
menare not intended 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,fire owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
ie builder will have bile burden of proving that he did not M1uiIJ or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,ant exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the pmjecl(Sec.7044,Burbles, LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
msd Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts Far such projectswith a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contactors Liecnse Law.
0 Ian.exempt ad,Sec. _,B.&P.C. "orihls WATER HEATER W/VENT 6.00
reason _
Owner Date _ WATER SYSTEM - 5.00 a.06 ACs.CATE FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby ATE. first I have a certificate of consent to sell-imure. ZONING ENG.SITE NO.
or a certilicatc of Workers'Compensation Insurance,or a cerliticJ
copy thereof(Sec.3800.Lab.0-).
Policy No. Company
O O Certitiedcopyishcrehyfurnishcd, FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is tiled with file city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑.1 Y ❑ N❑.
C = CIER7'[FICA'1'1;OF IEXEMPI'[ON FROM WORKERS'
ISSUANCE 70.00 IA.U'D ROOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG. ^ OD
d O (This section need not be completed if the permit is for one TOTAL tT Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or less;I
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
U become subject to tire Workers'Compensation Laws of California.
O w / p`I"' BUILDING CV72L 011
Date - Applicuni ALTER OR ADD TO MECH. 5.00 .��
} w NOTICE '1'0 APPLICANT: 11,after making)his Certilicale of Ex-
I.. ? emption,you should become subject in 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 deancd revoked. AIR HANDLING UNIT(TO 10=C.F.M) 4.00
. CONS"FRUCI'ION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE 3
I hereby affirm That there is a construction tending agency for EXHAUST HOOD(WITH DUCT) 5.00
theisnanw of bile work for which this permit is issued)Sec. MICROFILM
3097,,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 7r to
Lender,Address
FAN (SINGLE) 4.00
- IceNify tllatlhwe,read tills application and slate lh:n the
snore VENTILATION A ( G 1 (� p
information is correct. 1 agree to comply wish all city and county ING , eD
ordinances and state laws relating to building construction, and BOILER-_COM COMP(3 H.P.or 100,000 B.T.U.i 6.00
hereby authoriec representatives of this city to enter upon the BOILER-COMP )Over100,000BTWSEEFEESCH. MECHA CAL frljp
above nnntioned properly for inspection puffin -s.
(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 10.00 NSO C T.
IN
Indy in any way accrue against sal fly in conseyuanoe of the
•ru ling of ih limit. t MECH.CONT. I LIG NO. MECH. 'vt
. "•�Cn�"" TOTAL -J JDEW L /
Signature of Aicl Corel actor
ate
ppan
OFFICE COPY