11384 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
.BUILDING PROJECT I DENT]FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11384
ADOR g / 90
o�S/ r BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
i
OwNPH'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
G or 6qwasl JV PHON ^ l
NAMEH" S „5QS'^fP OUTLETS-SWITCHES-RECEP 10.00/1.00
^/IG LIC.NO LIGHTING FIXTURES 10.00/1.00
CONTRACT ons Sygn�Y� G APPLIANCES-RESIDENTIAL 4.00 eo
ADDRESS
PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS IDV ER 20.00 Qtr PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CI 5.00
ZIP EMP.MET R D P LE {NS?' 20.00
APPLICANTS MOTORS SEE FEE SCH. %•
ADDRESS
SERVICE C 20.00 .. "
woo LICENSED CONTRACTORS DECLARATIO gI3/
< U I Imreby aflirni That I am licensed under provisions of Clmpter 9 ISSUANCE DATE
y< i7 (commencing with Section 7000)of Division 3 of IhcOBusiness and BLDG. ELECT. PLG. MECH.
r D z Pl.fessions Codd 1xe is in e, m 'ce full forC- A ❑ ,�,/ ❑ ❑
as 0 2- License Cla Lic.Nan m be J�
Q m w Date Contractor
a m s BUILDING PERMIT
n: OWNER-BUILDER DECLARATION INFORMATION
¢o i
X I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w 3 u y VALUATION $/FT.
al Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
if Code:Any city or county which requires a penult to construct,alter,
w
¢ u,Be¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
CLL requires the applicant for such permit to file a signer)statement that TOTAL PERMIT TO
F
$ he is licensed pursuant to the provisions of theContractor'sisi.B License
Hi�' Law(Chapter 9(commencingwilh Section 7000)of Division3oflhc
4 c Business and Professions Code)or that he is exempt therefrom and QTY: PLUMBING PERMIT FEE
ar$ the basis for the allegedexemption,Any violation of Section 7031.5 STORIES TYPE CONSrR.
a by any applicant for a permit subjects the applicant toacivil penally ALTER-DRAIN -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
their sole compensation,will do the 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 iln proves thereon,and who does such work FIXTURES-PER TRAP 5,00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve-
mentsamButintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or no . - REB IND CON PB Omer
prove for purpose of sale.). I NDUSTRIAL WASTE INTER. 30.00
❑ I,as owner at the property,am exclusively contracting wind ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does nor apply
to an owner of property who huilds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I hive a certificate ofconsent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). ,
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z
H Cert � y � Ithcity inspection division.
O A plican
MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC ran CERTIFICATE.OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU COMPENSATION INSURANCE. PLG.CONTR, LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ IN❑
D Z hundred dollars($100)or less I -
U O I certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL b- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
a Date Applicant ALTER OR ADD TO MECH. 5.00
} DO NOTIC17 TO APPLICANT: If,after making this Certificate of Ex
♦- 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
U such provisions or this permit shall he deemed revoked, AIR HANDLING UNIT(TO 10MOOF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency tit EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATINGUNIT( 100,000B.T.U.)9.50 /i
Lender's Address ELECTRIC
I C
I certify )bar I have read his application and slate that the above VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 6.00
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 o1' MISC.- REFER TO ORD.
Cupertino against liub" les,judgments, costs and expenses which CONST.TAX
may in any way ac a against said City in consequence of the PERMIT ISSUANCE 10.00
grunting f is r MECH.CONT. LIC.NO. MECH.
f TOTAL TOTAL
Signatu 'of Applicant/Contractor ate -
�' >�b��y OSCE 77l/oScZ)OFFICE COC