11536 -AP•PLICANT'+TO FILL IN'INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PSRMITNUMBER
BUILDING- APPLICATION & PERMIT .,
°°°R a 11536
U I7 BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S J /I�- PLAN CHECK VALIDATION
W�,/ I\[���J Q" DT . ELECTRIC PERMIT FEE
D V
PHGNE a6- I
'.�.
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
Ito.NO. LIGHTINGFIXTURES 10.00/1:00 I' -
CONTRACTOR's
AOOR APPLIANCES-RESIDENTIAL 4.00 "
ESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) ' 20.00 PLAN CHECK FEE P.C.NO.
OR;
ENGINEER.
- LIC.rvo. SIGNS TRANS. 3.00 ,
ARCH.OR ENO. SPECIAL CIRCUIT $.00 PERMIT VALIDATION
ADDRESS f
ZIP EMP.METER OR POLE INS. 20.00 1
APPLICANT'S
ADDRESS
- MOTORS SEE FEE SCH.
SERVICE CHANGE, 20.00a BE
O o P LICIiNSED CONTRACTORS DECLARATION
a v - I hereby affirm that I am IICen Sed under provisions of Chap ler 9 ISSUANCE DAT.E
vHi< N (comnungng wlth`Seclion 70001,n1'Division 3 of❑Ie Business onA - BLOG,. E� s ME❑CH.
H m z Professions Code,and my license is in full force and effect. r JL}j]t,1
z 0 m - License Class Lic.Number
9 f w. Dale Contractor p����11AA�ist��.ts1y
S,w OWNER-BUILDER DECLARATION i yIWIRFOHMATIONIT
w;u EA I hereby affirm that Lam exempt from the Contractor's License' MISC..- REFER TO ORD '
VALE)
.. o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 ION $/FT./ CU
� - Cade:Anycity orcounty which requires a permit to construct,alter, Q(}
"Q Q Q improve;demolish,or repair any structure;prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
- D, requires the applicant for such permit to file a signed statement dmP. TOTAL PERMI TO
u w$ he is licensed pursuant to the provisions of the Contractor's License r
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe U �
a Bus Bess and Professions Code)or that he is exempt therefrom andQTY• PLUMBING PERMIT FEE
M $ the basis for the alleged exemption,Any violation of Section 7031.5 ,STORIES TYPE CONSTR.
ngbyany applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 , -
of not mom than five hundred dollars(8500).)'.
❑ l;as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered far."sale (Sec. 7044, Business and Professions DRAINS-FLOOR'ROOF,AR EA,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 FIXTURES-PER TRAP - 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended 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-EASYSTEM•OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int EA.,SYSTEM
prove for purpose of sale.). INDUSTRIAL WASTE INTER.' 30.00 RES . IND CON' 'PB Omar
❑ 1,as owner of the property,am exclusively contracting with Cl ❑ ❑ ❑ ❑
licensed contractors toconstruct 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 ,
contracts for such projects with a contractors)licensed pursuant to -SANITARY-STORM EA.200ft 10.00
the Contractor's License Law. SEWER / TRACT NO, PARCEL NO.
❑ lamexem under Sec. ;B.&P.C.far this - WATER HEATER W/VENT 6.00
U a,oG
O
[)a 7- WATER SYSTEM 5.00 ACC.DATE r ACC.FILE NO.
Ne
WORKERS'COMPENSATION DECLARATION 1 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
ropy thereof(Sec.3800,Lab.CJ. - -
- Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY P24
s Z Z• ❑ Certified copy is tiled with the city inspection division, MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ Y [:] N[:]
~ rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� CCR'I'I PICCOI OF EXEMPTION N ION RAN WORKERS'
W'� '� COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. - PLG.
Z (This section need not be completed if the permit is for one _ TOTAL Y❑ No Y C] ❑
N
hundred dOBarS(S 100)Or lCss.);
L) 0 1 certify that in the perfurmunee of the work for which this plir- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U` mit is issued;I shall not employ any person in any manner so as to .�
'become subject to the Workers'Compensation Laws of California.
'O a Date- Applicant ALTER OR ADD TO MECHI 5.00 ' BUILDING �C/V
} m NOTICE: TO APPLICANT: If,after making this Certificate of Ii x. -
F Z emption,you should become suhjeat to the Workers'Compensmioo APPLIANCE _ 5.00 PLAN CHECK
provisions of the Labor Code, ymI must forthwith comply with 'FEE
CJ such provisions or this permit shall be deemed}evoked AIR HANDLING UNIT(TO 1OSMC.F.M.) 4.00
x AIRHANDLING UNIT(OVER IO,000C.F.M.) 6.00 SEISMIC FEE .SO
- CONSTRUCTION LENDING AGENCY -
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. - MICROFILM
3097,Civ.CJ. 1 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
1 certify that I have read this application and state that lha above VENTILATION FAN (SINGLE) 4.00 ,
information is correct. 1 agree to comply with all city I county - PLUMBING
ordinances and rstate laws relating to building construction, an BOILER-UbMP13H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to emer 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 a �agamst said City in consequence of the PERMIT ISSUANCE 10.00
grant�jht MECH.CONT. LICNO. MECH.,TOTAL TOTALal/Contractor Date
OFFICE CO PV -