11569 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON
' 111i'.
PERMIT NUMBER
BUILDING APPLICATION &PERMIT
ADDRESS��t� D0K/6gGS AVE BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1156
9
OWNERS
PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE ,
MP-5. � �riA NORTON 1-�z�Z
PHONE
NAME c70Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME �-n T ((JJ��� 1 '�/��Cf/r)�J{(J'R
600 ' -'-•-L� No. 539V' LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADORE l I e ('�/.r �7
QI VITT v'-I1. PHONE `77-1 -(2]-) PANELS - 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER LIC NO SIGNS-TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS
zip EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
aooREss
SERVICE CHANGE 20.00 �/ /,,l
Woo LICENSED CONTRACTORS DECLARATION G�'b
U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
yam (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Code,an by license is in full fort t frg
Z o w _- . License C Lic.Number O
2..zF Date Contract.,
a m f t - BUILDING PERMIT
e W OWNER-BUILDER DECLARATION INFORMATION
o A MISC.- REFER TO ORD
h'xa ; y I hereby affirm that I am exempt from the Contractor's License
VALUATION $/FT.
u Ioa Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 10.00
w N Code:Any city or county which requiresa permit to construct,alter,
C ¢ Q Improve,demolish,or repair any structure,prior to its issuance,Spin ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL
n w oQ,^ mhe is licensed pursuant to the provisions of the Contractors License PERMIT TO
Fir Law(Chapter 9(comeHeingwithSection 7000).&Division3oflhe PL��
E 4 c Business and Professions Code)or that he is exempt therefrom and .
OTYPLUMBING PERMIT FEE
M H c� the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
a ; by any applicant far a permit subjects the applicant loo civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001):
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW 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 4r an owner of
properly 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 suchimprove-
mentsarenot intended or offered for sale.If,however,lire building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
.r improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have tie burden of proving Thal he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ 0 ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does not apply
to mowner of property who builds or improves thereon,and who LAWN SPRIN VER 5 (EA.) 1.00
contracts forsuch projeclswith a contractors)licensed pursuant to SANIT
SEWER- AR V-STORM EA.200ft/10.00
the Contractor's License Law. D TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. B.&P.C,fur this WATER E W 6.00
reason
Owner Date WATER VSTEM 5.00 ACC.DATE ACC.FILENO,
WORK ERS'COMPENSATION DECLARATION WATERT 5.00
1 hereby affirm that I have a certificate.(consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified A ZONING ENO.SITE NO.
copy thereof(See.3800,Lab.C.). b
Policy No. Company
Q ❑ Certified copy is hereby furnished. i FIRE SPRINK ENERGY T 29
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO D. Y [] N Y ❑ N�
CC y C17 RTIPICATE OF 17XEM PTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.I.C.
LU >. COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. DO Y� N� Y � N�
d O . (I ties Section need not be completed if the permit is for one TOTAL 0 V
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not anhploy: y person In oIry manner sn as to
O W b'ecoly�suhe Workers'C I Ih'tiol LJ,sof alifornia.
a Date11�L Applicant W� ALTER OR ADD TO MECH. 5.00 BUILDING
> N NOTICE TO APPLICANT: If,after making this Ce tificate of E.
I,. ? en ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you Cunt forthwith comply With FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name' HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
'• 1 certify that I have read this application and state 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.1 6.00 �Q
hereby authorize representatives of this city to enter upon tiro 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 of MISC.- . REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which pERM1T ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting f hs permh MECH.CONT. LIC.NO. MECH.
sy 8 G TOTAL TOTAL
Signature of i
App canl/Conte for
To
OFFICE COPY'