9232 ttlaI
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
t '-p BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
�w / v� .v✓'G'� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 3
OWNER'S
NAME PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT - FEE'
CNAME
ONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
mig
LES LIC.Na DTej LIGHTING FIXTURES 10.00/1.00
ADDRESS TqOR's APPLIANCES-RESIDENTIAL 4.00
/�r�'/'e7 tS]� PHONE O"-Q}./ PANELS 10.00
DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.NO SIGNS TRANS. 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
- ZIP TEMP.METER OR POLE INS. 20.00
ADDRESSTs MOTORS SEE FEE SCH. n ,
SERVICE CHANGE 20.00
wooLICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 P/j' '7
¢ w
u eu I hereby affirm that I am licensed under provisions of Chapter 9
rn ///
i¢ a
(annmencing with Section 7000)of Division 3 of tha Business and ISSUANCE DATEBLDG. ELECT. PLG. MECH.
0 N i LicLn Pimirusio la Cod m7 y liceltse is in full force and,eff - ❑ ❑ ❑
pzwW License Class (e_Con Number ZVY p'
Date Contractor (.'�y P(�_
¢ m s BUILDING PERMIT,
:
¢ 0 ae ¢ OWNER-BUILDER DECLARATION
D MISC.- REFER TO ORD INFORMATION
E:
�' I hereby affirm that I nm exempt from the Contractor's License '
u O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
I- - PERMIT ISSUANCE 10.00
0 Code:Any cityor countywhich structure,
permit loco issuact•alter,
to ¢ ¢O improve,demolish,or repair any shucture,prior to its issuance,also ELEC.OONTR, LIC.NO. ELEC.
m S requires the applicant for such permit to file n signed statement that TO
a W he is licensed pursuant to the provisions of the ContractorTOTAL
License PERnMIT TO
H z < La.(Chapter9(commencing with Section 7000)of Division 3 ofthe 70" 6-
q 4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I- $ the basis for the alleged exemption.Any violation ofScction 7031.5 STORIES TYPE CONSTR.
a.ar by any applicant for a permit subjects the applicant m a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,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,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 77 FIXTURES-PER TRAP 5.00 O SD.FT.FLOOR AREA TOTAL ACREAGE
is himself or through his own employees.Provided that such if
ments are not intended or offered for sale,ll',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of-proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omar
C3 . .
I,as owner of the properly,am exclusively contracting with E] El EI 0 El
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. '6.00 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 (EA.) 1.00
contracts for such projects with a contractm(s)licensed pursuant to SEWER-SANITARY-S .200ft
the Contractor's License Law. /10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec..,B.&P.C.for 0uis � W
Leas.... ATER HEATER Wfeffff 6.001
Owner Data WATER SYSTEM 5.00
\ ACC.DATE ACC.FILE NO,
WORKERS'COMPIiNSATION DECLARATION WATER TR EA IN QUIP. X11 .00
I hereby affirm that I have it certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified 0 ZONING ENG.SITE NO.
copy thereofeof( 00,Lalb.0puny ).y � GA �
Policy No Company
❑ Certified copy is hereby furnished.
'z Z Ycertified Copy is filed with the city inspection division. FIRE SPR INK ENERGY T-24
p Applicant MISC.- REFER TO ORD. v [:] Nv ❑ N�
CC W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W AT
� COMPENSATION INSURANC17 . PLG.CONTR. LIC NO. PLG.
0. O ('Phis section need not be completed if the permit is for one TOTAL dao Y O N Y [] N
Z) Z hundred dollars(S 100)or less)
U O 1 certify that in Da performance of the work for which this per' OTY. 'MECHANICAL PERMIT FEE FEE SUMMARY
U. F mil 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. -
0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>- W NO I'ICE TO APPLICANT: If,after making this Certificate of fix
F- Z carrion,you should become subject to the Workers'Conmematioo APPLIANCE 500 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with .C.1 FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AWC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify Ilia,I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
rumination is correct I agree hs comply with all city and county PLUMBING p
ordinances and state laws relating to building construclion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 d
herebherby authorize representatives This city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
y
authorize
property for inspection of this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs told expenses which - CONST.TAX
May in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
graph oft p i MECH.CONT. LIC.NO. MECH.
7 TOTAL TOTAL
Si re 01 I cant/ ontractor Date
OFFICE COPY