18697 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI - PERMIT NUMBER -
BUILDING APPLICATION & PERMIT B 18697.I ADORE
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME Pr� QTY. ELECTRIC PERMIT FEE
�� rJA DNE2r -z
CONTRACTORS
ry%%ME In�, 1 �^x ,,II n�x�� OUTLETS-SWITCHES•RECEP 10.00/1.00
IJ��� Alk Uc.rvD:y057.2515-0 LIGHTING FIXTURES 10.00/1.00
GONTRACTORs � _ APPLIANCES-RESIDENTIAL 4.00 -
ADDRESS 1 �/� -
d e, I��x.�Ei PRONE?- PANELS 10.00 DATE OF APPLICAT ION
OR
ARCHITECTPANEL$ (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.No.
ENGINEER
o. SIGNS TRANS. •3.00
ADDRRESS ENc' SPECIAL CIRCUIT.' 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
wo o - LICENSED CONTR'ACT'ORS DECLARATION PAID
iw 1 hereby affirm that I am licensed under provisions of Clapter9 ISSUANCE DATE
y<$ (commencing-with Section 7000)of Division 3 of the Business and DG. ELECT. PLG. MECH.
H N z Professions Code, license is in full fore U I`L D
o i w o License ;` Lic.Number - E
H w H j Dale Contructor��o
El
M ¢ w 4 OWNER-BUILDER DECLARATION hf of r`.gnq}jpa BUILDING PERMIT
w ° MISC.- - REFER TO ORD INFORMATION
g u E, I hereby affirm thal I am exempt from the Contractor's License
F .. O j Law for the following rcasoa(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which R•yuires a permit to consimcL alter, 10.00
0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
Om e requires the applicant for such permit to file a signed statement that TOTAL
w he N licensed pursuant to the provisions of 0m Csonlractor's License PERMIT TO
Hi > La..(Chapter 9(commencing with Section 7000)of Division 3 of the - '
4 c Business and Professions Cole)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
BEHoa lire basis for tire alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
dg _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP, RES.UNITS
their sole compensation•will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to al owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve.
Bents are not intended or offered for sale.If,however,the building GA$-EA.SYSTEM-11NE.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owne
builder will have the burden of proving that he did not build o,intr. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES 'IND . CON Pe Omer
❑ 1,as owner of thin property,um ceekoivcly contracting with
licensed contractors ID construct the.project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. - 6.00 1:1 ❑ ❑ ❑ ❑ 11
and Professions Code:The Contractor's License Law Joes not apply ASSESSORS PARCEL N0.
to an owner of property who builds 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.200f[/10.00
fire Contractor's License Law. TRACT NO. PARCEL N0.
❑ I am exempt under Sec. ,B-&P.C.for ibis WATER HEATER W/VENT 6.00
reason
OwnerDate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'ITDON DECLARATION WATER TREATING EQUIP.
I hereby affirm that 1 have a certificate of rousent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy there ofj 0,Lab.C.). x �Mp
Policy No.=(�onspany -
C) ❑ Certified cup' hereby furnished.
Z Z Certified y is fdgd v;i I dy iospe0im, division. FIRESPRINK ENERGY T 24
O Aplwanl MISC- REFER TO ORD. Yo NE] YE] NE
~ rn PERMIT ISSUANCE 10.00
LU -
CERTIFICATE OP SATIO'fINS FROM WORKERS' - - FLOOD ZONE A.L.U.C.
W > COMPIiNSATION INSURANCE PLG.cONTR. LIC.NO. - Plc. - '
(L a ('This section need not be completed if the permit is for one TOTAL Y Y ❑ IN
Z) Z hundred dollars($IOOlor less.).
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- 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 Calitornia_
Date A Ilcant BUILDING
} tail NOTICE'1'O APPLICANT: If,after making this Certificate of ALTER OR ADD TO MECH. 5.00
F ? Ex-
emption,you should become subject m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK _
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit Shull he deemed revoked. AIR HANDLING UNIT(TO 100MC.F.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 EXHAUST HOOD (WITH DUCT) 5.00 q �Q
- lire pertoriance of the work for which this permit is issued(Sec. , MICROFILM
3097,Civ.C.). HEATING UNIT(T0100000 B.T.U.) 8.00 • -
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's AAJress ELECTRIC
1 certify that 1 have,cad this application and sure 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.Or 100,000 B.T.U.) 6.00
herebhereby authorize representatives ec This city tO enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL I.
y
authorize
property far inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs nod expenses which PERMIT ISSUANCE OR CONST.TAX'
may in any way accrue against said City in consequence of the
randlis permit ,'� A MECH.CONT. LIQ N MECH,
�(/ pl� TOT Lr _ TOTAL oZ/_ oD
Signature ol'Applicant/Cont ractor ate 3 IbE�
OFFICE COPY