10162 APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 10162
aDDREss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNEn$ PLAN CHECK VALIDATION
N E
. QTY. ELECTRIC PERMIT FEE
PHONf
NAMERA Rs . UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No LIGHTING FIXTURES' 10.00/1.00
ADDRESS 64 APPLIANCES;RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT l PLAN CHECK FEE P.C.N0.
OR PANELS (OVER 200 AMP) 20.00 (!V
ENGINEER
LIC.NO. •SIGNS TRANS. PAID 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.MET R ,q P LE INS:,J 20.00
APPLICANTSjZ MOTORS SEE FEE SCH.
eSERVICE CH 20.00
o¢ i p
Foo LICENSED CONTRACTORS DECLARATION G TEMP.POLE 30.00 U
a u I hereby affirm that I am licensed under provisions of Chapter 9 gg 7
N a a (commenting with Section 7000)of Division 3 Litho Business and ISSUAftE DAYE
SLOG. ELECT. PLG. MECH.
r o z Professions Cn •,and license is in full force�wl ❑ ❑ ❑
z° z w° Licen h s Lic.Number3-��
_ Date ContractorIc
� utF
a m BUIL'DING;PERMIT,:- -
¢ ¢ m a
OWNER-BUILDER DECLARATION
°o. c' MISC.- REFER TO ORD INFORMATION; r
A.
; N I hereby affirm Ira[I am exempt from the Contractor's License
u O sc Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- g PERMIT ISSUANCE 10.00
toi Code:Any city or county which requires permit to construct,alter, �•
rcX a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.L
°¢ requires the applicant for such permit to file a signed statement that TOTA
n m u he is licensed pursuant to the provisions of the Contractor's License PE�O
w
a, Law(Chapter 96hurmencing with Section 7000)ol'Division 3 ofthe -
4 ao Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE Z
¢ s-$ the basis for the alleged exemption.Any violation of Section 7031.5 1 1
STORIES - TYPE CONSTR.
i ; .- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages us BACK FLOW PROTECTDEVICE 400
their sole compensation,will do file work,and the structure is not . .
OCC.GROUP RES.UNITS
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 SO,FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such Improve-
mentsarenotintendedorofferedforsale.If,however,lite building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner
builder will have the burden of roving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ P,as owner of the property,am exclusively'contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 600 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply . -
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for amh projects with a contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
❑ lam exempt under Sec, ,Iis.P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.OATE. ACC,FILE NO.
WORKERS'COMPHISSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofcoasent to self-insure,
or a certificate of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ CertifiedLopy is hereby fumishcd.
Z Z � Cetlifie cu Is 01 i�,��city inspection division. FIRE SPRINK ENERGY T-24
p Applicant G(.0(d,(,C! MISC- REFER TO ORD. YE N❑ Y ❑ NE)
jr W CRRTIFICATEOF EXI NPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UG.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y 0 N Y❑ NC]
� Z hundred dollars(S100)orless.)
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE`SUMMARY
LL U mit Is issued,I shall not employ any person In any manner so as to
become subject to the Workers'Compensation Laws of California.
> i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
- Do NOTICE TO APPLICANT: If,after making this Certificate of bx-
? Cmption,you should become subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
U
provisions of the Labor Code, you must forthwith comply with FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for I EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state chid the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree i comply with all nstrund county BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws rending to comply
with 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 forinspe of
purposes.
(We) agree to save, Ginbannify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Bab' ies,judgments, costs and expanse which CONST.TAX
may in any way a ue a9 insl mid'Oy i consequent of the PERMIT ISSUANCE 10.00
grantin f t is ib MECH.CONT. LIC.N0. MECH.
WIPTOTAL TOTAL
Sign of ppicant Contractor
dt v5 c8 77gOSCftl a'�`a�
OFFICE
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