10903 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOING PROJECT IDENTIFICATION PERMIT NUMBER
soILDING APPLICATION & PERMIT 10903
ooRESS p
• iCI rj TEEN CRGEK�UI-✓/� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME v{,t. C:0}',/'
Q , ELECTRIC PERMIT' FEE
W,L. M/12OCCODK'HDNE40073`1-03 '+
NAME OUTLETS jE, UTLETS-SWITCHES-RECEP 10.00/1.00 2 3[-
call ,kirlwU k cc2•.T,ee_gC 41C.NO, / 7 L/&,737_ ),;j_3 LIGHTING FIXTURES 10.00/1,00 ) 3
CONTRACTOR'S /,, PPLIANCES-RESIDENTIAL 4.00
ADDRESS Yy(i ��yy
7/"f L, rV&4,YN A✓6 PHONE /"/trt,& J PANELS 16.00 /IJ,CL DATE OF APPLICATION
ARCHITECT PANELS 200 AMP) 26,06 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS, 3.00
ADDRESS ENc' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS " ' SEE FEE SCH. 3�`'cU
AGGRESS - LI
71I C . r rZ0* AI',E 3 'P'ALE SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION -K
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
H "' (commencing with Section 7000)of Division 3 of the Business and
4 w BLDG. ELECT. PLC. MECH.
F O i Professions Code,and my license is in full force and gffect. ❑ ❑ ❑
Z
0,y, License Cla{s 'g n Lie.Number 1 7 Y6-97
Q m w Dete 1/� R t- Contractor-,ci .N>41n/4 '_6 L_'C�'
a - E Isvf. BUILDING PERMIT
cr y T C OWNER-BUILDER DECLARATION '"
a a o INFORMATION _
X 5 w m 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- s R ER TO ORD VALUATION
H w o 4 Law for the following reason,(SeC.7031.5,Bosinessand Professions / PERMIT ISSUANCE 10.00 /O,O f/FT.
Code:Any city or county which requires permit to construct,alter,
re aa a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. p ELEC.
0 u requires the applicant for such permit to file a signed statement that Cts! TOTAL /�67�C0 PERMIT TO
w K $ he is licensed pursuant m the provisions of the Contractor's License
F ' i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe '^ , lr LCC-;f
E i o Business and Professions Code)or that he is exempt therefrom and OTY.r;: -PLUMBING PERMIT.- _ "fFEE
H$ the basis for the alleged exemption.Any violation Of Section 7031.5 '', A-I ��` - "-�. STORIES TYPE CONSTR.
d ; _ by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN&VENT-WATER (.. 5.00
of not more than five hundred dollars($500).1:
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP REB.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec. 704, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does notho o an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sD.Pr.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided that such im
mm
es are not intended or offered for sale.If,however,the building
GAS-EA.SYSTEM-11NC.40UTLETS 8.00
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 am- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 RE5 IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
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 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 contractorls)licensed pursuant to SEWER-SANITARY-STORM EA.200hI10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insu re, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
opy thereof(Sec 3800,La b.C.L,
Policy No. Company
0 ❑ Certified copy is hereby furnished.ENC IOb 00 FIRE SPRINK ENERGY T 24
Z Z 154 Certified copy is filed with the city inspection division.
Applicant ^ iP-¢T WC -L Tal 12NP MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Fw
CERTIFICATEOh-EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION CCOMOMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. v❑ N❑ v ❑ IN
CL O (This section need not be completed if the permit is for one TOTAL
:DZ hundred dollars(S IAO)or less.) S_ k - " ,
L) O 1 certify that in the performance of the work for which this per, 1 ~ - I•, _1. - 1 ' FEE SUMMARY
W F mit is issued,I shall not employ any person in any manner so as to ATV'M1,' t + ` %MECHANICAL PERMIT,.' . , FEE
O W become subject to the Workers'Compensation Laws of Califomsa.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex'
F 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
C) 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 10=C.FM.) 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
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9,50 ELECTRIC C
I certify that 1 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 stale laws relating to building construction, and BOILER-CONPOH.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 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 CONST.TAX
may i By way acme against mid City in consequence of the PERMIT ISSUANCE 10.00
grant of this pe MECH.CONT. LIC.NO. MECH.
- l c/ 22,3_ TOTAL TOTAL
Signature of App icant/C tractor ate
OFFICE COPY