3011 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I L DING PROJECT I DENTIFI• V PERMIT NUMBER
aUILQInG APPLICATION & PU_. .T 3 011
OGRESS nn II
-7/0 S J'
_,!FtA �icti BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME /1 �J DTV. ELECTRIC PERMIT FEEe-
0r1 �. 1J@ �.QV NrPNONE L��_qI7Jt'
NTRAcroRs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. _ LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
ADDRESS
DAPPLIANCES-RESIDENTIAL 4.00
NTRAC
PHONE PANELS 5.00 DATE OF APPLICATION -
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P,C.NO.
OR
ENGINEER
uc No. SIGNS TRANS. 3.00
AMC"
AODR EOR SS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
APPLICANTS
AGGRESS .�J MOTORS SEE FEE SCH. 1(�
SERVICE CHANGE 10.00
S/0
0 0 o LICENSI-D CONTRACTORS DECLARATION ti
A u I hereby affirm that I am licensed under provisions of Chapter 9 tSSuary CE DATE
rt (contmencmg who Section 7000)of Division 3 of the Business And BLDG. ELECT. PLG. MECH.
H o¢ Professions Code.and my license is in full force and effect ❑ ❑ ❑
oz m o License Class Lie.Number
m r Dace Contract.,
¢ y s RU ILDING PERMIT
IF tc w ¢ OWNER-BUILDER DECLARATION AID INFORMATION
A OAU MISC.- REFER TO ORD
LA ; LL H I hereby affirm that I am exempt from the Contractor's
License VALUATION SIFT.
.. oQ Law far the following reason. 703 I.S.Businessand l'rolessions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to emst,uct alter. [P/1�p
Kic¢ ¢ 2O improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC.
-Ore recon,,the appl cAut for .to permit to file A signed statement that TOTAL PERMIT TO l?/ J 7
A w $ he is licensed pursuant to the provisions of the Contractor's License
Hii Law)Chapter9lcommencingwilh Section]OOOIofDivision3Ofdm f9W18L
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ t the basis for the alleged exemption,An -
g p Any of Se c lion malty STORIES TYPE CONSTR.
o ; by any ore applicant fora PermitSubjects the 01.1: am toacivil penally ALTER-DRAIN -WATER (EA.) 4.00 VA/
of not more than live hundred dollars 155001.1:
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their one 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. 4.00 ? ��
• Code:The Contractor's License Law does not apply to an owner of O
property who builds or improve%thereon,and who does such work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 leq
O
Or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING uSE
builder will have the burden of proving that he did not build or It.- RES IND CON USE,
Other
ptoye for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
Sp` 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. 5.00 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 36-7-/7-OY
contracts for such projects with it contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA, 200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date d C WATER SYSTEM 4.00 ACC.OATE ACC.FILENO.
WORK I*RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of WorkersCompensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy Nn. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant V❑ N❑ Y ❑ N❑ ,
CC y CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL,U.C.
LLI > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
Q. 0 (This section need not be completed if the permit is for one TOTAL V CD N❑ V EJ N❑
hundred dollars 45 100)or less.)
U 0 I certify that in the performance of the work for which this per, OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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. /�y V pp
CIA Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING T�/C
} m NOTICE TO APPLICANT: If,after making this Certificate of fix
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK A
provisions of the Labor Code, you must forthwith comply with FEE 9/j- .4--oU such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE,
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 '
the performance of the work lot which this permit is Issued)Sec. MICROFILM
3097.Cie CI. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I certify that I have read this application and ail c that the above VENTILATION FAN (SINGLE) 3.00
ordinances is street I agree to comply with all city and county PLUMBING
ordinances and stole laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 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 PERMIT ISSUANCE 3.00 CONST.TAX �pxi 2'0
may in any way accrue against said City in consequence of the
granting this permit MECH.CONT, LIC.NO. MECH,
yrs+ C��eaGE as/11p, t Y� OTAL TOTAL 9 �d�7
Sign tare of Applicant/Contractor Dace
OFFICE COPY