11270 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
2, 5e BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 11270
N NFa'S� O�� r PLAN CHECK VALIDATION
/A-�Jf1E�1 QTY. ELECTRIC PERMIT FEE
00
PHON
CONT ciORs UTLETS-SWITC
HES
-RECEP 10,00/1.00
NAME' � �pqN 'MegeII(Q
DdhOIJ�( Z'w uc.NO. (7 LIGHTIN3' XTURES 10.00/1.00
CONTRACTOR SP
PLIANCES-RESIDENTIAL 4.00
0ADDRESS 3643 Foltolr.A St'
(Q PHONE r- (� PANELS 10.00 DATE OF APPLICATION
Gi PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.rvo. � SIGNS TRANS. 3.00
ARCH.OR END SPECIALCIRCUIT $,00 PERMIT VALIDATION
Zlv TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CON'(RAC'1'ORS D17CLARATION
< v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h , (commencing with Section 7000)of Division 3 of the Business and
a L G. ELECT. PLG. MECH.
H N i Professions Co y 11 ease is in full force �d effru-
oi m O Licen lass Lic. -
H w H j Dater �1ML b-Cmuncto,
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
o i v INFORMATION
I I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
p1 ;o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
S - -' Code:Any city or county which requires permit to construct,alter,
a x < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
In
o LL requires the applicant for such permit to file a signed statement that TOTAL
n w$ he Is licensed pursuant to the provisions of the Contractor's License 1 PERMIT TO
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Ea Business and Professions Code)or that he is exempt therefrom and QTY. ' ;PLUMBING PERMIT FEE ottyoo
io
¢ I- $ the basnyap Or the alleged ermit subjects
tsthAny ea plica of Section malty ( . STORIES TYPE CONSTR.
n ; _ by any applicant fora permit subjects the0).): ant too Civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(E500).1:
❑ I,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(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code,The Contractors License Law does not apply to an 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-
•' ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prv Or purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES, IND CON PB Omer
-f I,as owner of the property,am exclusively contracting with
licensed,contractors to construct the project(See.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 5 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STOflMEA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
rea❑ I um exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
son
Owner Date WATER SYSTEM 5.0 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 nApplic��n
rtified c py is hereby furnished. FIRE SPRINK ENERGY T24
Z
Zifie opy is file i lie ci ins di division. MISC.- REFER TO ORD.
VE] N Y [] No
TI
Oh EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be Completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D 2 hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- DTY. MECHANICAL PERMIT FEE FEE SUMMARY
5
LL mit is issued,I shall not employ any person in any manner so as In
U become subject to the Workers'Compensation Laws of California. '
GIG Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>. 0 NOTICE.TO APPLICANT: If,after making this Certificate of L'x-
Z emption,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 10=C.F.M-) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency]or 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 H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
• 1 certify that I have read this application and state(hat 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
hereby authorize representatives of this city to enter upon the BOILER-COMP loser 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' PERMIT ISSUANCE 10.00 CONST.TAX
may yyyyi llinlgggg any way accrue against said City in consequence of the
gra ofthls per // � MECH.CONT. LIC.NO. MECH.
.lam-��*U .044�C G�z�e� TOTAL TOTAL
�Ignatuleo pplicant/Contractor Dat D
OFFICE COPY