11865 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING
-MECHANICALADESS 011 BUILDING-ELECTRICAL-PLUMBING
PLAN CHECK VALIDATION 517
OWNER'S
Nnrr QTY. ELECTRIC PERMIT FEE
L/7-1r/ PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
` NA E iv LIC.Noes W LIGHTING FIXTURES 10.00/1.00
.ONTRACTOR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 UHm Uls APPLICATION
d �` 20.00 PLAN CHECK FEE P.C.NO.
ARCHITECT PANELS (OVER 200 AMP)
ENGINEER SIGNS TRANS. 3.00
LIC.N0. PERMIT VALIDATION
ARCH.08 ENO. SPECIALCIRCUIT 5.00
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20:00
Osz
, 02 LICENSED CONTRACTORS DECLARATIONU U 1 hereby affirm that I am licensed under provisions of Chapter 9 Ci 101'LE AC6 OATS
�N
N ¢w (commencing with Section 7000)of Division 3 of the Business and BLOC: ELEC -PLG. MECN.
F, Professions Cod a my license is iu full for efR,c}, /
z o Lice 1 ass Lic.Number DD �.)L
El
o m�. Date Contractor
BUILDING PERMIT
a
at w¢ OWNER-BUILDER UECL ATION
3 n REFER TO ORD INFORMATION
v -
ww I hereby affirm that I am exempt from the Contractor's License MISC. VALUATION
Fro J Law for the followingreason.(Sec.7031.5,BuSlnessind Professions PERMIT ISSUANCE 10.00
vs Cod¢:Any City ar County which requiTCSa Permit to construct,alter, ELEC.CONTR. LIG NO.
f w P im rove,demolish,or repair any structure,prior m ins issuance,also ELEC.
a: er Q O P TOTAL PERMIT TO
i e u requires the applicant for such permit m file a signed sbdemem that /
X$ he is licensed pursuant to the provisions of the Contractor's License �-'�
r a i Law(Chapter9(<mnmeneing with Section 7000)of Division3of the FEE`.
Q Business and Professions Code)or that IIc is exempt therefrom and QTY. PLUMBING PERMIT STORIES TYPE CONSTR.
ve s O
o: I-$ the basis for the alleged exemption.Any violation of Section 7031.5
a ; � by any applicanTforu pemnit subjects the applicanttoacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Of not mom than five Imndred dollars($5001 J'.
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT.DEV ICE 4.00 OCC.GROUP REG.UNITS
their wle compensation,will do the work,and the structure is not
intendeJ ar 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 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP
himself or through his own employees,provided that Such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
ments are not intended or Offered for Sale If,however,the building
or IMProvernem is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2,00 BUILDING USE
builder will have the burden of Proving that he did not build ar m- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exClusivcly contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 6 V.B. 6.00 ASSESSORS PARCEL 110.
and Professions Cade: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
comructs for such projects with a contractor(s)licensed Pursuant to SEWER-SAN ITARV-STORM EA.20011/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for This WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE N0.
WORKERS'COMPENSATION DECLARA1 ION WATER TREATING EQUIP. 5.00
1 hereby afrrm that I have a certificate of consent to self-insure, ZONING ENG,SITE NO.
or a cc,lifialle of Workers'Compensation Insurance,or a ecru ied
Ycopy there IS X100,fab.C. .a,•
x PolicyN�i_��QeompanY FIRE SPRINK ENERGY T24
O ❑ Corti ed copy is hereby furnish d.
Certili�fOLoP is fled IT the fy inspection division.PC
.- r REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Q ppliciot,i� 2 -s!4
F u- /- 'S MITISSUANCE 10.00 FLOOD ZONE A.Luccc - CERTIFICA'1liOPEXEMPTIONPROMWORK CRS' PLO
W D COMPENSATION INSURANCE LIC.NO. TOTALY❑ N❑ Y ❑ NO (Phis section need not be completed if the Permit is for one
D Z hundred dollars IS 100)or less.) FEE SUMMARY
L) O I certify that in the performance of the work for which this per- MECHANICAL PERMIT FEE
F mil is issued,1 shall not mnPlDy any person in any manner 10;1,to S v
LLU become subject to the Work eri Compensation Laws of'California. BUILDING
O lu Datc Applicaof ALTER OR ADD TO MECH. 5.00
} W NOTICE '1'0 APPLICANT If,after making this C¢rlificalc of Ex- 5.00 PLAN CHECK 3 7
H ? em Plion,you should become subject m the Workers'Compensation APPLIANCE /
provisions of the Labor Code, you must forthwith comply with AIR HANDLING UNIT(TO 1Q000C.F.M.) 4.00 FEE
such provisions or this permit shall be deem it revoked.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE . .S_O
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,Civ.C.).
Lender's Name HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FANS INGLE) 4.00 PLUMBING
information is correct.I agree to comply with all city and county BOILER-COMP(3H.P.or 100,000 B.T.U.) 6.00
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP to.,100,00013TUISEE 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 ;md expenses which CONST.TAX
may in an way accrue agai t said City in consequence of the PERMIT ISSUANCE 10.00
grunting is perini. , / / MECH,CONT. L16 NO. MECH. -7
,(/ , �� ✓YJ/Z TOTAL TOTAL ��
i L✓
�ignalu of Applicam/Comrector atT
OFFICE COPY