15567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
BOILDINGPROJECTIDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT [[ C�"j
ADDRESS J J 6 1
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL /•
OWNER' o PLAN CHECK VALIDATION
rvAME I QTY. ELECTRIC PERMIT FEE
J41 PHGNE
CONTRACTOR.
NA E a I Q UTLETS-SWITCHES-RECEP 10.00/1.00 _
A/ uc.No 7 LIGHTING FIXTURES 10.00/1.00
ADDRESS
r. GRs - - APPLIANCES-RESIDENTIAL 4.00
REss CC.. � q
�� a�, PRONE pC
' PANELS 10.00 DATE OF APPLICATION t
RRcufTticT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCH.OR ADDRESS END" - - SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
aoUREss SERVICE CHANGE CHANGE 20.00
o
H
02 LICENSIiD CC1NTkACI'URS DECLARATION - s
<u w 1 hereby afOral that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n (commencing with Section 7000)of Division 3 of the Business mtd
¢ BLDG. ELECT. PLG. MECH.
r w i Professions Co a license,is in full fr tT e!f �J ❑ ❑
p�� L (j O`
Zo Z m D License Class `a'�Lic.Nombur /
H m H w Date � Contractor -
¢ o w - OWNER-BUILDER DECLARAFION BUILDING PERMIT
K
ig LL N I hereby affirm that I am exempt from the Contractor's License
. MISC.— REFER TO OR INFORMATION
ua. lalw for the following reason. 7031.5,Businessand Professions VALUATION
PERMIT ISSUANCE 10.00
Fw Code:Any city or county which mcniresa permit to construct,alter,
Q ¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. _ LIC.NO. ELEC.
ca
LL requires the applicant for such permit IO file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
r z a Law(Chapter 9(commencing with Section 7000)ol'Division 3 of the 1
4 O Business and Professions Code)or thin he is exempt therefrom and DTV. PLUMBING PERMIT FEE F8
at the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 - by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(55001.1:
` ❑ 1,as owner 9f the property,or'my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale 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. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who buildspr improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
.Cuts l o not int h his own employees.provided however,
such improve-
mmsello .throe h]its or n employees,
ees,or p JL ed that s tie building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not build or im - . - . .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Otner
-- - - --❑' 1,as owner of the property,am exclusively contracting with ❑ 0 ❑ ❑
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 docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with I contractors)licensed pursuant to SEWER-SANITARYV-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ 1 am exempt under Sec. - ,BARE.for this WATER HEATER W/VENT ,Gb
reason Jy
Owner Date WATER SYSTEM P' f"l ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
.I hereby athin,'that I have a certificate of consent to self-insure,
or a certificate of Worker:Compensation Insurance or a cerlificd ( ZONING ENG.SITE NO.
copy t 80 Lab.C.).
Policy Co puny {
0 ❑ r If cu y is h oc y famished. city �1 up r ) FIRE SPRINK ENERGY T-Z4
~ O pp,Cenil' ttpy is Rla1 with'Ne city inspection division. MISC.- REFER TO ORD. Y N v N
A hLant � � [ .o
CC y CG ICATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 1660 __IDFLOOD ZONE A.L.U.C.
LU 1 COMPP.N'SATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
I.CL( This section need not he compleluA if the permit is for one TOTAL ad,) Y❑ N[3 V [3 NEI
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of file work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
UL H mit is Issued,I shall not employ any person In any manner so as to
O U become subject to the Workers'Compensation Laws of California.
Date—Applicant BUILDING
}'0. NOTICE TO APPLICANT: If,after making this Certificate of Pix- ALTER OR ADD TO MECH. 5.00
♦— ? emphon,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 this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10M)CF.M.) 4.00 t
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00CEM.) 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(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMPI3 H.P.Of 100,000 B.T.U.) 6.00
hereby aulhoriec representatives of this city to enter upon the
DI ahove•nsenlion property far inspeclinn purposes, BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
,(W6) agree t save, indemnify and keep hamiless the City of MISC.- REFER TO ORD.
Cupertino agains liabilities,judgmenl,, costs and expenses which PERMIT'ISSUANCE 10.00 CONST,TAX
any way ccrue against said City in consequence of the
res ti .fit
per it, MECH.CONT. . LIC.NO. MECH.
TOTAL TOTAL
Sig t reef Applicam/Contmclor Dat
OFFICE COPY