11048 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS e 11048
i( 4 yb ICU
OWNER'Sy/ PLAN CHECK VALIDATION
" "f OTY. ELECTRIC PERMIT FEE
PHONE
co ACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
NA
,)[ LIC.NG LIGHTING FIXTURES 10.00/1.00
offs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
04 (i(� PHGNE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLANCHEF77 P.C.NO.
OR
ENGINEER
LAC.No. SIGNS TRANS. 3.00
ARCH,OR END. SPECIAL CIRCUIT S.OQ PERMIT VALIDATION
ADDRESS
zlv TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH, d.W�ptiF-
ADOREss s
� SERVICE CHANGE 20.00
K • �^
o o LICIiNSEU CONTRACTORS DIiCLA ATION ��// • s�
a U u I hereby affirm that I am licensed under provisions of Chapter 9
ISS
UA CE GATE
vHi<W (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.' MECH.
F w i Professions Code and ppppiy license is in full for pu ❑ ❑ ❑
z o m a, DaensoC ss Co Number , -
Q m r w Date Contractor
c y f ' BUILDING PERMIT
It ¢w u OWNER-BUILDER DECLARATION INFORMATION
a MISC.- REFER TO ORD
E
; a LL s- 1 hereby affirm that I am exempt from the Contractor's License
H LL 0< Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE 10.00 VALUATION .$/FT.
rA0 Cade:Any city or county which requires a permit to construct,alter,
rc ¢Q a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
oc
o ce requires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
H no a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ?L�'
sio
Business and Professions Code)or That he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ F the basis for the alleged exemption.Any violation of Section 7031.5
malty STORIES TYPE CONSTR.
by any applicant fora permit subjectsthe$5000.licanl toacivil penalty ALTER-DRAIN So VENT-WATER of not more than five hundred dollars(5500)J:
❑ 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 ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Low does not apply to an owner of
property who(mild,Or improve,lllemon,and who does such work FIXTURES-PER TRAP 5.00 1 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 EASYSTEM OVER 4 IEA) 200
x, builder will have the burden of proving that h - . - . .
e did not build or am- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 'RES IND CON PB Omar
Cl 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
Iiccnscd contractors to Construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL 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 contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 p
the Contractor's License Law. p TRACT NO. PARCEL NO.
O I am exempt under Sec.-,B.&P.C.for this WATER HEATER T W/ 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPHNSATION DECLARATION WATER TREAT IR, E:w 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure. a-i
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy ls}l fr Yfunf bed. FIRE SPRINK ENERGY T-24
Z 2 �Certi d y/�� ed no I the city inspection division.
O ApplicantZ A-q� - MISC.- RE TO ORD. Y ❑ N❑ Y ❑ N❑
CC m CER9'IIICATI:OF EXIiMP` N FROM WORKERS' PERMIT ISSUANCE 10.00 AQ FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
1 O This section need not be completed if the permit is for one TOTAL 3 Y❑ N Y❑ N❑
D 2 hu n dred dollars 1$IOD)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NO"I'ICE TO APPLICANT: If,after making this Certificate of Ex- -
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN,CHECK
provisions of the Labor Code, you most 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 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that then is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name H EATI NG LIN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify Nat I have read this application and state ,at the above VENTILATION FAN (SINGLE) 4.00 ,M(�
information is correct. I agree to comply with all city and county PLUMBING 3 y=
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.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 in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gr nti n f Perini MECH.CONT. LIC.NO. MECH.
,M ^ 3 jlbz, TOTAL TOTAL
Ignature of Applicant/Contracto Data
OFFICE COPY