2099 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICAT PERMIT NurBE I
BUILDING APPLICATION & PER, F 'gyp 9 9
ADDRESS /
' '<V TOUILDING -ELECTRICAL-PLUMBING-MECHANICAL
Spa
O N R'S . gin' F { hit (• v •,p ty.-pf Lo?. PLAN CHECK VALIDATION
N�AaME.(,� p n/S^�I OTY ELECTRIC PERMITI �, &",s y FEE;'
P J' AP«oNE e• ,; I ,.. , :_.at`s rid'-:..
NAME TORS UTLETS-SWITCHES•-RECEP 5.00/1.00 5
NAME C17
-Tat
uc.No LIGHTING FIXTURES 5.00/1.00 7s �� 6
CONTRACTORS'
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
DREss _
ONE PANELS 5.00 DATE OF APPLICATION
AR «ITECT SIGNS 6,DD PLAN CHECK FEE P.C.NO.
�
roriWoR OIV
ENGINEER
LIC.No, SIGNS TRANS. 3.00
AARCH.OR DDRESS END SPECIAL CIRCUIT 5.OD PERMIT VALIDATION
zlr TEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
i'g 0105 SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and SLOG. LECT. PLG. MECH.
iProfessions Cod Ln my license is in full f q
. Is - Licen ss Lie.Number.J.7 �J ❑ ❑
a r w Date Contractar�� _
( y JBUILDING PERMIT'."a.
Z p; W a OWNER-BUILDER DECLARATION 7" INFORMATIONI •'' ..j!
oa ° MISC. REFER TO ORD ° 'V
1 hereby affirm that 1 am exempt from the Business
Pr License VALUATION
ILO Low for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 -
Emyr Code:Any city orcounty which requires a permit to construct,alter.
e 5 a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. lJd
-O LL requires the applicant for such permit to file a Signed statement that TOTAL / PERMIT TO
' w$< he is licensed Pursuant the provisions of the Contractors License
Hir Law(Chepmr9(commenencingwrth Section 7000)ofDivision3oflhe
4 er Business and Professions Code)or that he is exempt therefrom and GTV. ;'-.•n�_;- PLUMBING PERMIT {j" ;-FEE
g:r o the basis for the alleged exemption.Any violation ofSedion 7031.5 I mss_' Z,.q, .--c'. Sts' •:'` •I•• -'• •'�` S/T�ORIES TYPE CONSTR.
;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA) 400 �/
of not mart than five hundred dollars(S500)J: e/�
131,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 GROUP RES,UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA.COND. 4.00 _2 /
Code:
The Contractor's License Law does not apply to an owner of ✓
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. IJ
f ments arc not intended or offered for sale.IL however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 a
f.' or improvement is sold within one year of completion,the owner- ryyQy S A)WR 4(EA.) 1.00 BUILDING USE
Y builder will have the burden of proving that he did not build or im- `VIY f RES IND CON PB Omer
prove for purpose of sale.). INDUSTRI AL WASTE INTER. 20.00 ��
❑ 1,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business L I 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NnO,
and Pmfcun owns or Codeproperty Contractor's License Law does not apply
to an owner of properly who builds 's improves thereon.and who LAWN SP L -OVER 5 (EA.) 1.00
contracts for such projects with a contracto s)licensed pursuant to
the Contractor's License Law. SEWER' RY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
C, I am exe p under Sec. .BAP.C.for this WATE W/VENT 4.00
rcaw Fit
Date ' owner WATER SYSTEM - 4.00 Ace.DATE ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconvent to self-insure. ONIf4G
or a certificate of Workers Compensation Insurance,ora certified // ENG.SITE NO.
copy thereat(Sec.3800,Lab.C.)�+ ,./�(
eae
Policy No. Company 6 y.��•K/sLZ�(6'K'^
0 ❑ Certified y is hereby f nlshed. FIRE SPRINK ENERGY T-24
Z ZO ❑ Cenife py Is file itl t in. 'n ection division. MISC.- REFER TO ORD.
APPlicant v v N
= H CE TIFICATE OF EXEMPTION FROM YORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE ."At000.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
t1 O (This section need not he completed if the permit is for one TOTAL Y❑. TLJ "'LJ
:3 Z hundred dollars(S 100)or less.) - - - -
U O 1 certifythat in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE'SUM1111i
IL P mit is issued.I shall not employ any person in any manner so as to
O hecomc suyy{��1�5dItj�the Workers'Com��tly .aws of Calilinnia.
0 y 'Dec0, f &pplicant-J L /! ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If after making this Certificate of Ex-
F Z emption,you should become subject to the Workcri Compensation APPLIANCE 4.00 PLAN CHECK g r�}p
provisions of the Labor Code, you must forthwith comply with FEE �[/��(y L.�LT
C� such provisions or this permit shall be deemed revoked AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,0001C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.0,C.1. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Name
Lender's e
LendersamAddress- HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
I certif)'that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER•ODMP(3 H.P.or 100,000 B.T.U.) 4.00
•hereby authorize representatives of this city 10 enter upon the BOILER-COMP 10",100.000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wel agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses Which CONST.TAX
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE 3.00
grants of this perms MECH.CONT. LIC.NO. MECH. ,.
TOTAL TOTAL (03 (O
gnature of Applicant/Commdor ate
OFFICE COPY