11870 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�T BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
„GILDING APPLICATION & PERMIT ,
aooREss /�/ � 11870aZD�/ .� .STB/�G��1S C..Q6Ea� ,BIJOU BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ,
OWNER'5 mss^ PLAN CHECK VALIDATION
NAME
C,-^c/U/�(1/�J�IV t-r, Q DTV. ELECTRIC PERMIT FEE
�d-/IIQD �V IJS 7;ePHONE���✓/�i
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
elwJY.cAL z�--AevCOO-eLIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRASDNTRACTafls
APPLIANCES-RESIDENTIAL 4.00
PHONE -(J,S' PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
' UC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'$
AMOTORS SEE FEE SCH:
DDRESS
,2S 4,e/ES =f; S-2. SERVICE CHANGE 20.00
w
02 LICENSED CONTRACTORS DECL ATION
rt U I hereby affirm that I an licenser)under provisions of Chapter 9 ISSUANCE DATE
yza (commencing with Section 7000)of Division 3 of the Business and -
¢ w BLDG. ELECT. PLC. MECH.
r D i Professions Code,�y1d Wy icense is in full force
p'nd -1'•- O El F_ LEI y 0Lic.Number
'= - License Class �Z
4 H w Date �8 Contractor�t..:d T_Aq
a Y E LSO-.'tAC'' BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER D17CLARATION
BE
a " MISC.- REFER TO ORD INFORMATION
E:
g:LL I- I hereby affirm that I am exempt from the Contractor's License
H LLD¢ Law for the followingrcuson.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
IS a ¢ Improve,demolish,or repair any structure,prior LG Its Issuance,also ELEG CONTR. LIC.NO EC.
C¢ requires the applicant for such permit to file a signed statement that T TAL PERMIT TO
¢ w m" he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commeneingwith Section 7000)of Division 3 ofthe 10Le6.
a easiness and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ = $ the basis for the alleged exemption,An
g p he applicn ofSection703I.5
penally STORIES TYPE CONSTR.
i ; by any applicant fora permit subjects the applicant to u civil penally
of not more than five hundred dollars(8500).): ALTER-DRAIN& ER 1EA.1 5.00 :5
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole to ensatm n,will Jo she work,and she structure is not
intended or 0 red for sale (Sec. 7044, Business and Profess' or DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Com lei's License Law does no apply to an per of
properly who bur or improves thereon,and who doe Ch work FIXTURES-PER TRAP 5.00 O SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through s own employees,provided tha cit improve-
mentsarenotintendr or offered for sale.If,ho per,the bmIdrng GAS-EA.SYSTEM-iINC.4OUTLETS 6.00
or improvement is sol ithin one year of co lesion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the bu en of proving lis a did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the pr erty, exclusively contracting with El ❑ ❑ 0 ❑
licensed contractors m const the project(Sec. 7044,Business LAWN SPRINKLERS-I INCIt V:B. 6.00 ASSESSORS PARCEL NO.
and Professions Core:*fire tors License Law dues not apply
to an owner of propert to bur or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such pr Ess with a co actor(s)Ircensecipursuant to
the Contractor's Ase Law. SEWER-SANITARY-STORM (1.200ft/10.00 �Q TRACT NO, PARCEL NO.
❑ lam exe tunder Sec. ,B.&P.C.m,Ihls WATER HEATER W/VENT )••.6:00
reason
Owner Dale WATER SYSTEM �+ 5.00
n'td �\ ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP 5.00
I hereby affirm that I have a certificate of consent so salf-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy there f IS 8 0,Lab.C.). �/�
Policy N w C ompany HI/Af
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z f�Certifi cop is filed y Ity upec ' L div'slon.
O Applicant // G- �, Cl� MISC.. REFER TO ORD. YC] NN[]
� �2 CERTIFICATEOF FXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 49,Qa FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PL CONTR. LIC.NO. PLG.
1 D (This section need not be completed if lite permit is for one /✓ .9 TOTAL �''� Y N� v N�
:) Z hundred dollars(SI00)or less.)
U O 1 certify that in a performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall employ an mrllr'ny manner so as to
0 W become subject so the mperea"on Laws of California.
Date an BUILDING
OIL P ALTER OR ADD TO MECH. 5.00
} m NOTICE TOA CAN'T: If,aIle caking chis Certificate of Ex�
♦- 2 emption,you should become subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
Prov'
simss of the Labor Code, you must forthwith kohl Ply will) FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000CF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
.the performance the work for which this permit is' d.fSec. MICROFILM
3097,Civ.CJ. - 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 Certify4.00-
information
that) ercaagree application and all c that and
caboveounty VENTILATION FAN (SINGLE) 4.00
information n 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 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for Inspection purposes, BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 in any way account, against said City in eenSBqucnce of the
granting of ispC it. O/ MECH.CONT. LIC.NO. MECH.
�-0?3 TOTAL TOTAL
Ignature of Applicant/Contractor Date
OFFICE COPY