11643 APPLICANT TO FILL.IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER-
BUILDING
APPLICATION & PERMIT,
ADDRESS / 00 ,.` / - G'� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11643
wE
ONR'S �a�C - PLAN CHECK VALIDATION
� "AM%J� I - DTV. ELECTRIC PERMIT FEE
PHONE
I/Y
CONTRACTORS j3(
i36 S-SWITCHES-RECEP 1000/1.00
rtlllY�G 0LIGHTING FIXTURES 10.00/1.00 .Q' S
CONTRACTOR s, - - APPLIANCES-RESIDENTIAL .4.00
ADDRESS �J/J}JC',/ �/R '7--r') ,
2 J.L (J tJ/1�� PHOrvE {V�` PANELS 10.00 •' DATE OF APPLICATION
ARCHITECT , PANELS (OVER 200 AMP) 20.00 ' PLAN CHECK FEE P.C.No.
OR
ENGINEER
LIC. SIGNS TRANS. 3.00 -
ARCH.ORENG. SPECIAL CIRCUIT
5.00 ,PER MIT VALI DATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPucANT s - MOTORS I SEE FEE SCH.
ADDRESS p/
SERVICE,CEHANGE• p 20.00
w0 O ' LICENSED CONTRACTORS D17CLARATION '-
`< u'U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
'y a i (cmnnnencing with Section 7000)of Division'3 of the Business and - n, - BLDG. ELECT. I PLG. MECH.
H N i Professions Cod and ildhense is in full for}�c��pL1 fe I 0 ❑, ❑
z o w - icense ss $v Lia Number Sl - I - ❑
0 ate -Rei-Contraclo y�
a Y E - BUILDING PERMIT -
Ic ¢ OWNER-BUILDER DLCLARAT16N INFORMATION
So>eJ MIS REFER TO ORD
X ; u I hereby collo that I am exempt from the Contractor's License
uo¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Q VALUATION $/FT.
� - Code:Any city or county which requires to construct,alter,
at au rt Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL v PERMIT TO
" w 8 he is licensed pursuant to the provisions of the Contractor's License
�zQ
Law(Chapter 9'(commencing with Section 7000)of Division 3 ofthe -
F Business and Professions Code)Or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IF file basis for thCailegedexemptioh.Any violation of Seclion703L5 ' STORIES TYPECONSTR:
by any applicant fora permit subjects the applicant to a civil penalty - ALTER-DRAIN -WATER (EA.), 5.00
of not more than five hundred dollars($500).): '
Cl I„as owner of the property,or illy employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or 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 - -
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTALACREAGE
'• himself or through his own employees.provided that such improve.
cents are not intended or offered for sale.If,however,the budding 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). 2.00 ' BUILDING USE
builder will have the burden of proving that h . .
e did not build im- RES IND CON PB Omer
prove for purpose ofsale.). INDUSTRIALWASTE INTER. 30.00 ❑ El El 1:1 1:1❑ 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 PAHCELNO.
and Professions Code:The Contractor's License Law does not apply
m an Owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Cutnocts for such projects with a C(.ntraetorls)licensed pursuant to
the Contrnetur's License'Law' SEWER-SANITARY-STORMEA.200tt/10.00 - TRACT NO. PARCEL NO. ;
[3 I ran exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
rCaS'DII - '
Owner Date WATER SYSTEM 5.00 . r ACC.DATE ACG FILE NO.
WORKF.RS'COMPENSA]ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy Drereof(Sec:3800,Lab.CJ.
Policy No. Company
.0 O Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z,Z ❑ Certified'Copy is ffel with the city inspection division. Ni REFER TO ORD.
O Applicant - - - Y❑ N❑ Y E] N[]
CIiRI'IFICATE 'ROM PERMIT ISSUANCE 10.00 ` FLOOD ZONE 'A.L.U.C.
LU . ATIOORKF.RS'
LUCOMPEE COMPENSATION INSURANCE PLG.CONTR. LIC.NO. LG. -
-CL O IT his section'Toed not be uon.pleted if the permit is for one TOTAL- Y❑ N❑ Y ❑'- N❑
D Z hundred dollars(5100)or less.)
L) O 1 certify that in the performance of IN,work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall riot employ any person in any manner s0 as to
O beeolp�sub'- t�q,t[it Workers•.Cy�ngrllsat,, alit Fair.
Deco 10 APPLICANT:
_d'-l� ALTER OR ADD TO MECH. 5.00 BUILDING
NO'I']CIi TO APPLICANT: If,'Ater making this Cerli cafe of Ex-
F ? emption,'you should become subject to the Workers' ompensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall redeemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4'.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 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. HEATING UNIT(TO 100,000 B.T.U.1 B.00 - MICROFILM
3097,Civ.C.). q
Lender's Namc -
,Lem er's Address HEATING UNIT(OVER 100,000 B.T.U.)9,50 ELECTRIC
certify that l have read thiaapplication and state that the above VENTILATION FAN (SINGLE) 4.00 _,
I
information is correct. I agree to comply with all,city and county PLUMBING
ordinances and state laws•relating.to buildingconstruction, and - BOILER-COMP(3 H,P.Dr 100,000 B.T.U.) 6.00
hereby,authorize representatives of this city he enter ,on lilt BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
'I 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
g" Pe MECH.CONT. LIC.NO. MECH.
3
�eC 6 TOTAL TOTAL
ature of Applicant/Contract Date
COFFICE COPY