18534 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT 8
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aooREss
*2 loT AI c" D BUILDING - ELECTRICAL-PLUMBING -MECHANICAL 5 /�
A
.1,. OWNER'S - PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE
r
V_A-T1Ay Ts AN
PHOrvE
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
- LIC.No. LIGHTING FIXTURES. - 10.00/1.00 b
DDR's
ADDRESS
� qG-38960 APPLIANCES-RESIDENTIAL 4.00
ORE55 / ,
PHONE PANELS' 10.00 DATE OF APPLICATION
0gcHlTEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINE H
Llc.No. • SIGNS TRANS. 3.00
ADDRESS ENG. SPE I L CI IT 5,00 PERMIT,VALIDATION
A1Gt4:, -OA HA Q ZIP TEMV.ME R OR POLE INS. 20.00 ! ��
APPUCANTS M
ADDRESS SEE FEE SCH. l
'S-f3/sj .,M-is- CA _ Sl'2- R ANGE PAW, 20.00
F o O LICENSED CONTRACTORS DECLARATION
a i w I hereby uf'finn that 1 anI licensed under provisions of Chapter 4h'
t. , I ISSUANCE DATE
r (commencing with Section 7000)of Division 3 of rho Business and
w a H -` BLDG. ELECT. PLG. M .
•F.0 N z Professions Code,and my license is in full force and effect.
z o w- License Class-Liu.Number ppI I"\/}e'-
o m F Date Contractor gibL/1 4�IRI no-
rc s w¢
OWNER-BUILDER DECLARA'T'IONtd Q IC^�. IfVI 'V BUILDING PERMIT
- O W. " IS R TO ORD INFORMATION
K
; LL I- I hereby affirm that I am exempt from the Contractor's License
H u o¢ Law for the FAlowingreason.(Sec.7031.5,Business and Profess ions I U 10.00 �.a VALUATION $/FT.
w m Code:Any city oncouaty which rcqulresu pennd ro constructalter, �.,-r 2' O ,
¢ ¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. �j L E EC. S z/
a
D ¢ requires the applicant for such permit to file a signed statement that TE / YTAL'4 0;1_3
7 Z3
lam
he is licensed pursuant nthe with provisionsofthe Contractor's Sol Ilse ( PERMIT TO
H z i Law(Chapterand
Professions
Code)with Section is"l of t therefion o and
G
a Business for
Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE VES
� i o
¢ F a the basis for the alleged exemption.Any violut.ip of Section 7031.$ STORIES TYPE CONSTR.
i ;m by any applicant for a permit subjects the applicant(oa civil penalty
of not more than five hundred dollars 15500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wuges 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,AR EA,COND.' 5.00
Code',The Contractor's License Law does not apply to an owner of ,
prbperty who builds or improves fiction,and who does such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided thus such improve- �I
/ hients mself a through
rimmndcd or offered employees,
or provided that s the hulloing GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
j h1 or
m
improveent is sold within one year of completion,the ownery
builder will have the burden of proving tint he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
_. pro've for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB ' Omer
1,as owner of the property,am exclusively contracting with
lic'nsed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:T'Iw Contractor's License Law does oat apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 -.t/L'r; Qvl TI V f'� 1
I 1
contracts for such projects with n contructorls)licensed pursuant to cN /
the Contractors SEWER-SANITARY-STORM EA.200ft L..License Law. /10.00 TRACT NO, PARCEL NO.
❑ lame pt undor Sec. ,B.&I'.C.I'or this WATER HEATER W/VENT 6.00
reason
Owner_ Dule i2f9 WATER SYSTEM 5.00 - ACC.DATE ACC.FILE No.
WORKERS'COMPENSATI DECLARATION WATER TREATING EQUIP. 5.00
�I I hereby affirm (flat I have a certificate of conical to seli-insure,
pr a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE.NO.
copy thereof(Sec.3800,Lab.C.). -
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TP9
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO OR D.
0 Applicant V Ny ❑ .N�
CERTI FICATE 01:EXEMPTION FROM WO R KERS' PERMIT ISSUANCE 10.00 12,0b FLOOD ZONE A.L.U.C.
LLI 0 - COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLGCL . /L7 V N V'� N�
(1 his section need not be completed if rhe Parrott is for one TOTAL 1 7
=) Z lunulred dollars IS 100)or less.)
U O I certify that in the performance of ate work I'or which"'is per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any honer so as to
become subject to the Workers'Compensation Laws of California.
Ca. Date Applicant BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex ALTER OR ADD TO MECH. 5.00 6 6,�•
F ? emption,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 provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MO C.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the 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 100,000 B.T.U.)9.50 t•�p -L3
Lender's Address ELECTRIC
]-certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct. 1 agree ti comply with all city and county PLUMBING y0 Zj
ordinances and shite lows relating In building l city uction,and co andmy BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
heieby authorize representatives of this city to enter upon the g01 LER-COMP IOver 100,000 BTU)SEE FEE SC Z 7..
abovom.enrioned property for inspection purposes, 9-( ? MECHANICAL �4/p 3
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
'- ma any way accrue 'g s City in consequence of the PERMIT ISSUANCE 10.00 1ZF� /
ra in Of this ennit MECH.CONT. - LIC.NO. MECH.
TOTAL
TOTAL Ll
Signature of Applicant/Contractor Date
OFFICE COPY