11189 :;ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
I I
�C. ADDR S 1 - e BUILDING -ELECTRICAL-PLUMBING-MECHANICALII189
OWNEn'S h,N PLAN CHECK VALIDATION
rvAME '7 TV. ELECTRIC PERMIT FEE
PHON F •-
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
l N C.NO '550q972 LIGHTING FIXTURES 10.00/1.00
.DNTRACTORs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
*70 f- C NE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
on
ENGINEER
Ltc.rvo. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. /J
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N a H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D Professions Cod rend 'cense Is in full for am e f c ❑ ❑ ❑
z o 0 - Lice IT lass Lie.Number
oOulc
Contractor
w F
a a w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
u REFER TO ORD INFORMATION
w ;LL N I herebyaffirm that I am exem 1 from the Contractor's License MISC.-
p VALUATION $/FT.
u0¢ Law for the following reason.(Sec.7031.5.Business and Professions -PERMIT ISSUANCE 10.00
Fy0J Code:Any chyorcounly which requires a permit to construct,alter,
se a, Q Improve,demolish,Or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
LaCc he Is licensed pursuant to the provisions of the Contractor's License Al
F z a Law(Chapter 9(commencing with Section 7000)of Division3of the / f��,�
F i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 sa.Pr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-l 6.00
mots are not intended or offered for sale.11,however,it,,building
or improvement is sold within one ycdr of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that hC did not build or im' RES IND CON PB O too
prove for pu.'pose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to:n owner of property who builds or improves Dmmom,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects With a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractors License Law.
Cl I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 qCC.DATE ACC.FILE NO.
WORK I!RS'COMPENSA'IION DECLARA'T'ION WATER TREATING EQUIP, 5.00
I hereby aRnm that I have a certificate of consent to sell-Insure. ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy there�of(`Sey,��0�0,L]a1 b.C.),.���q�.
Policy Nob& L4yl-l->•���
Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T.24
Z Z7�, x9f Certify�d g> Is mi w.ikthe c y inspection division. MISC.- REFER TO ORD. y N� y ❑ N[]
O Applicanl_CT'�aRiTT' �
� N CERTIFICA'I'EOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU c.
LU COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG.OTAL y� N[3 v � N❑
D- O ('flus section need not be completed if the permit is for one T
Z hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL h- Init is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workeri Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MEC 5.00
} N NOTICE TO APPLICANT If,after making this Certificate of Fs-
F" ? combon,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 provons or this permit shall be deemed revoked AIR HANDLING UNI 10,000 C.F.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(QyEPJ*Rq,EMA 6.00 SEISMIC FEE
I hereby re affirm that theis a construction lending agency for EXHAUST HOOD ( UC ) 5.00
m
the perforance of the work for which this permit is issued ISec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)9.50 , ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this City to enter upon the 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 and expenses which /O CONST.TAX
may any way acerue,a incl said Oity in consequence of the PERMIT ISSU NC 10.00
In 11 go [h is peanut. MECH.CONT,g- I M CH.
,\ TOTALO D TOTAL
Signature of Applicant/Contra t Uatc• II �(/� '
OFFICE COPY