10972 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BVILDmG , _ APPLICATION & PERMIT
ADDRESS __ 10972
STEVCvvd'CrQEEK �L,/o, BUILDING-ELECTRICAL'-PLUMBING-MECHANICAL
OWNER'S .e�s � - - PLAN CHECK VALIDATION
� "AME U /a � DTV. ELECTRIC PERMIT FEE
HONE
CONTRACTORS _ OUTLETS-SWITCHES-RECEP 10.00/1.00
_ NPM M _uO NO. 24�_ LIGHTING FIXTURES 10.00/1.00 -
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS 1#- Z48-
PHON PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE. P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.OR
DDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDDRDRESS
n -
AMOTORS SEE FEE SCH.
\
a SERVICE CHANG E' 20.00
woo LICENSED CONTRACTORS DIiCLARATION
a v w I hereby afliml that I um licensed under provisions of Chapter 9 ISSUANCE DATE
H G Promotion C icoa l 700e i of Division of yLByy i94ss and - BLDG. ELECT. PLG. MECH.
_ ,n,0 Professions Code!/��yififll�A,AA''license is in full forjTiiLLYI// ❑
Z o,n - License ass Lic.Number -_y.A. r ❑
� L w Uale_27 01,Uactor
L . .. BUILDING PERMIT
S, w a OWNER-BUILDER DECLARATION INFORMATION
MISC.- ' REFER TO ORD
X3:;LL H I hereby affirm that I am exempt from the Contractor's License VALUATION
F LL 0 4 Law For the tbllowiag reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any eityorcounty which requires a permit to construct,alter, -
ar u12 Improve,denudis,,cu m,an any structure,prior 10 Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
K O SE requires the applicant for such permit to file a signed stater en1 that TOTAL pER
A is m" In.is licensed pursuant to the provisions of the Contractor's License ^A
H z r
Law(Chapter 9(commmcing will,Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
t=-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjectsthe applicant to a civil penally ALTER -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.INRs
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 does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
aremsare not intended'or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement 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 or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC_'5 V.B. 6.00 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 a
contracts for such projects with a contructons)licensed pursuant to SEWER-SAN EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO./
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT - 6.00
reason
Owner Dale WATER SYSTEM . 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION ' . WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent m self-insure, - ZONING
nr a certificate of Workers'Comp emotion Insurance,or u ecrlifiud ENG.SITE N0.
copy ll, t,t u any �Myr( �y -
PolicYN t mny_C�9
0 ❑ CCrl I1led Copy u1 eby turnished. FIRESPRINK EN ERG T 24
Z Z �Certi ' copy {'f�_le-d_w�ith the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O Appl icunl_Ylf PT Y N V N
~ to ' / a PERMIT ISSUANCE 10.00
„ � - CFR IFICATIi OF EXEMPTION IrROM WORKERS' FLOOD ZONE A.Lu.C.
LU > COMPENSATION INSURANCE ' PLG.CONTE. LIC.NO. PLG.
0 (This section need not be completed if the permit is for one TOTAL Y❑ N[3Y❑ N[]
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LLL F mil 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 Date - ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} ti NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensut ion - APPLIANCE 5.00 - PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT( A00G 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 1 . .M.) 6.00 SEISMICFEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WULT) \ 0
the performance�of'tIhe war Por ich'lhis permit is issued(Sce. MICROFILM
3097,CIv.C.). (/�"� (/V/I}p,pj� HEATING UNIT(TO .0,000 8.00
Lender's ban, HEATING HEATING UNIT(OVER, OB.T.U.19.50
Lender's Address ELECTRIC
I certify lhm I have read this application IuW slate that Om above .'L VENTILATION FAN (SINGLE), 4.00
information is correct.1 agree to comply with all city and county - - PLUMBING
ordinances and state laws relating to building mnstnmlion, and Z BOILER H.P. 100,000 B.T.U.) 6.00 Z' -
41 hereby aathorue representatives of this city 10 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 ugainst said City in consequence of the 'PERMIT ISSUANCE 10.00 Q
r gra ti this per MECH.CONT., LIC.NO. MECH.
3 -9 TOTAL vo TOTAL
Signa re of Applicant/ tractor Date -
OFFICE COPY - ,