10159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION gppLICATION & PERMIT PERMIT NUMBER
ADD ISG 1015 9
aooREon
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
4C
= - PLAN CHECK VALIDATION
QTS'• ELECTRIC PERMIT " FEE
PHONE
coryAME TRa .'s UTLETS-SWITCHES-RECEP 10.00/1.00
Np'
LIC,NO. O LIGHTING FIXTURES 10.00/1.00
nooaess lam PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
DR U PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
AENG. LIC.NO. SIGNS TRANS. 3.00
ADDRESS DREBS _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPucgrvrs .SEE FEE SCH
AOORESS ♦ 0 MOTORS
i
SERVICE CHANGE 20.00 O /�
o �
Foo LICENSED CONTRACTORS DECCARAT N TEMP,POLE 30.00
,x tU E, I hereby affirm that I an,licensed under provisions of Chapter 9 ISSUANCE DATE
v,Q w (commencing with Section 7000)of Division 3 of the Business and - ,
H N Z Professions Cod and m license is in full force L.e A' BLDG. ELECT. PLG. MECH.
o
0. -O License 1' s Lic.Numbcr (/
e r w Dalc Comnr,tor. ;� ❑ L-Y ❑ ❑
Q y E
M c w < OWNER-BUILDER DECLARATION i I r n7� BUILDING PERMIT `
E
;LL H I hereby affirm flet 1 am exempt from the Contractor's hinnse MISC.- REFER TO ORD
INFORMATION
r u o j Law for the 1'ollOwing reason.(Sec.7031.5,Business and Professions VALUATION
iw� Code:Any city or county which requifesa permit toconstruct,alteq PERMIT ISSUANCE,, r•,} f�Rpprllnh 10.00
ta 40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONT.. LIC.,NO. ELEC.q
u n o u requires the applicant for such permit to file a signed statement that ELECT,
TOTA
X
$ he i6 IicensW porsuunt m the porvisions of the Contr.,dar's License 40 PER IT TO
Hii I-uw(Clmpmr9fcommencingwiBl Section 7000)01'Division3of the /
PER
p
F i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT 'FEE
rz F the basis for the alleged exemption.Any violation of Section 703 t.5 STORIES ♦ TYPE CONSTR.
a ;� by any applicant forapermit subjects the applicant loacivil ponalt ALTER-DRAIN o(not more than five handed dollars(55001): 'y (EA.) 5.00
❑ 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 Profs DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply loan owner essionof
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.00 50.FT.FLOOfl A.EA TOTgL ACREgGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GA$-EA.SYSTEM-1INC.40UTLETS
er-
6.00
or improvement is sold within one year of completion, the own
e,will have the burden of proving that he did not build or im- GAS-EA.-SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB omar
❑ I,as owner of the property,am exclusively contracting with ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLER$-1 INC 5 V.B. 6.00
ID F-1
and Professions Code:Tire Contractor's License Law does not apply ASSESSORS PARCEL N0.
10 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 -
Contracts for such projects with a cuntractoos)licensed pursuant to
the Con tractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRAcr No. PARCEL No.
❑ I nm exempt under Sec. ,B.&Y.C.Inr(his
rwson WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKfiRS'COMPfiNSATION DECLARATIONWATER TREATING EQUIP, 5.00
- 1 hereby affirm that I have a certificate ofeonsenl m self-insure,
or a cerlificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab.C.).
Policy No. Company
❑ Certllied copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z `�Cerlifie of is fiI tut ty inspection division.
♦- O Applicant- �" MISC.- REFER TO ORD. Y❑ N❑ v ❑ N[]
f1' N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
LL 1 COMPENSATION INSURANCE PLG.CONTR. FLOOD ZONE
CL O " LIC.NO. PLG.
::3 Z (This seclion need not be complete) if the pennil is for one TOTAL V❑ N Y N
U O hundred dollars(5100)or less)
I certify that in the performance of the work for which this per- QTY 'MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued, I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws 01'California.
IL Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE; TO APPLICANT: If,after making this CertiNcate 0f Ex-
I- Z emPtmn,you should become subject to the Workers'Compensation App LIANCE 5.00 PLAN CHECK
provisions of the Labor Colic, you must forthwi til Comply with
V such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10p000.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIRHANDLINGUNIT(OVER IO,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction holding agency for - EXHAUST HOOD (WITHDUCT)
Lender's Name 5.00
the Performance of Bre work far which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 9.00
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city ID enter upon file
above-mentioned property for inspection purposes. BOI LER-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 'ndgmenls, costs and expenses which CONST.TAX
may in any way accrue gai st said Cirsnin oUse u..ence o1'the PERMIT ISSUANCE 10.00
granting of Illi peryi ✓ MECH.CONT. LIC.NO. MECH.
/ /� TOTAL TOTAL
Signora Ppli<aCnt/Contractorn�7�( Da I f
&00.
FFICFjCOPY
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