11116 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
�` ADo E�s 1 0 ► s;
` 1 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11116
OWNER'S '1 PLAN CHECK VALIDATION
IZP
�V TY. ELECTRIC PERMIT FEE
HONE
crrvreacroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
"A1 1U CA Vl�`1
LICNO. LIGHTING FIXTURES 10.00/1.00
r-
TRACTORS -RESIDENTIAL 4.00
vEE�3UV til fo 4�s 2,
PHO `,• PANELS 10.00 DATE OF APPLICATION
ARCNITEciPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
IIP EMP.METER OR POLE INS. 20,00 PAI
ADDRESS
ADOREss MOTORS SEE FEE SCH. Lp�Q/f1�
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION '
¢ mo P I hereby af00n that I am licensed under provisions of Chapter 9 NCE TE
m<N (commencing with Section 70001 of Uirision 3 of the Business and BL El 11 H MECH.
r 7 z Professions Ccnlc license is in full forcy f P32
z o y- License Class `••� ` Lic.Number ` �7 /
Q m !w Date Contractor-.�11_.n�.-.A` -
¢ s: s a �R��� BUILDING PERMIT
2 ¢ w u OWNER-BUILDER DECLARATION INFORMATION
oa MISC.- REFER TO ORD
E:
; LL y I hereby affirm that I am exempt frons the Contractor's License VALUATION $/FT.
H u_o J Law for the following reason.(Sec.7031.5,Businessand Professions pERM1T ISSUANCE 10.00 rj'1
Code:Any city or county which requires a permit to construct,alter, J`-'
¢ ¢<2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ,
m, requires the applifant for such permit to file a signed statement that - TOTAL MI TO
a. w he is licensed pursuant to the provisions of the Contractor's License PER'/T
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe E'y UL<7F7
E¢ o Business and Professions Code)o .r that he is exempt Therefrom and QTYPLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.)'5.00
of not more than five hundred dollars(8500).):
❑ I,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,COND. 5.00
Code:'file 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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 INTER. 30.00 RES IND CON Pa Omar
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct ole 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 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Tum exenspt under Sec. ,B.&P.c.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK F:RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.CJ.
Policy No. Cmnpany
O Certified copy ishereby furnished. FIRE SPRINK ENERGY T-24
Z
❑ Certify copy Is filed 't Ilse city it pection division. MISC.- - REFER TO ORD.
O APPlicant-N-�(y��r ' Y❑ N❑ Y❑ N❑
~ rn Y - "��
LU � CERTIFICATECER11FICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.U.C.
W COMPENSTION
INSURANCE PLG.CONTR. LIC.No. PLc.
d O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollars 1$100)orless.)
U O 1 certify that in the perRvmance of file work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 0_0 IS
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
Z_ eruption,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 suds provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,WOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance M 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 EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
• 1 certify that I have read this application and state Thal fie above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. 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
ma 'n any way eccr�ft og s[ said Cit in cop sequence of the
gr Citi g lilts if// MECH.CONT. LIC.NO. MECH.
`7/�-•il• Y C-� /[' - TOTAL TOTAL
Signature of Applicant/Conttactor ++/VCV�--
OFFICE COPY