10736 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDIN1G APPLICATION & PERMIT 107 36
ADDRESS ^ �g l e of BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"FME IM rS L II <<C DTV. ELECTRIC PERMIT FEE
PHONER�a
CONTRACTOR'S Io-1/ Cr TNC UTLETS-SWITCHES-RECEP 10.00/1.00
tn bt � CIA!nzLIGHTING FIXTURES 10.00/1.00
Co TRACTOR'SPPLIANCES-RESIDENTIAL 4.00
Ap E //�
�o bj r HONEgb 'J22
PANELS 10.00 DATE OF APPLICATION
RCeITECT PLANCHECK P.C.NO.
OR PANELS (OVER 200 AMP( 20.00 I
ENGINEER
Llc.uo. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS ^ SPECIAL CIRCUIT 5,00 J
�/�- zlP EMP.METER OR POLE INS. 20,00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS ,^ x
14 'LIB) SERVICE CHANGE 20.00
-,0o LICENSED CONTRACTORS DECLARATION A le
¢ u v I hereby affirmthat I am licensed under provisions of Chapter9 PAID
ISSUANCE DATE
h <h (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
F N z Professions Cod and my 1'cense is in full fort effect I '1 f�o ❑ ❑
oz O m .icensc CP ss 4 Lic.Number JAN 15 19(;,
r w a[c Conitactar
¢ se f �'hC'• BUILDING PERMIT
¢ O n U
OWNER-BUILDER DECLARATION MISC.- F D INFORMATION
X 3 r 1 hereby affirm that I am exempt from the Contractor's License
w d VALUATION S/FT.
H _¢0J Law for the following reason.(See.703 1.5,Businessamd Professions PERMIT ISSUANCE
W Code:Any city or county whichrequiresa permit to construct,alter,
Q ¢¢� improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. 0C.NO. ELEC.
DLL requires the applicant for such permit to File a signed statement that TOTAL PERMIT Tp,
n w$ he is licensed pursuant to the provisions of the Contractor's License
r z t
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he isexempt therefrom and DTVPLUMBING PERMIT FEE
¢ = g .the basis for the alleged exemption.Any violation of Section1031.5 STORIES TYPE CONSTR.
dy _ by any applicant for u permit subjects the applicant to a civil penalty ALTER•DRAIN& VENT-WATER (EA.) 5.OD
of not more than five hundred dollars($500).):
❑ I,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 for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,GOND. 5,00
Cade: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-
Tentsarenotintended or offered for sale.l l',however,the building GAS-EA.SVSTEM-iINC.40UTLETs 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 200 BUILDING use
builder will have the burden of proving that he did not build or int . . .
RES IND CON PB Omer
th
prove for purpose of e.)' INDUSTRIAL WASTE INTER3000 1:1 El E] ❑ 1:1❑ I,as owner of the property,aexclusively contracting with . .
licensed contractors to construct thm lu
e 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 In SEWER-SANITARY-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
WATER HEATER W/VENT 6.00
reason
Owner Dme WATER SYSTEM PAID 5.00 ACC.OATE ACC.FILE NO
WORKERS' ENSATI NDECLARATION WATER TREATING EQUIP. 5.00
I hereby affmr Khat ave a cerlifm-are of consent m self-insure, �,
or a cellifmcz 1 o rs'Compurs, ion Insurance,or a certified I q ZONING ENG SITE N0.
_ copy there ,Lab.C. � �
Policy No. 0 any r'r'"F–*
O ❑ Cer G y or
hed' Mi rt)IIO FIRE SPRINK ENERGY T.24 '
Z'Z ❑ C til" J 0 d h the city inspection division. ❑ ❑ ❑ ❑
F ppplir t MISC.- r REFER TO ORD. v N Y N
Do CE T I AlI'E OP EXEMP'T'ION PROM WORK
PERMIT ISSUANCE 10.00' u' FLOOD ZONE A.L.U.C.
W'- COMPENSATION INSURANCE PLG.CQNTR. LIC.NO, PLO. NNE] v NN[]CL 0 (This section need not he completed if the permit is for one TOTAL v
hundred dollars(S 100)cur less.)
U 0 I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL - mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
y Date Applicant BUILDING
} to NOTICE TO APPLICANT: If,after making this CcrliFicmc of mix- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,CODC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10XDC.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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Lender')Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC oZ
I certify that I.Imvc read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 -eA,
information is"correct. I agree to comply with all city and county PLUMBING
ordinances and state laws rating to building construction, and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 6.00
It
authorize repress Ives Of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned pr per Lnicuts,
purposes.
(We) afire t , ' demeep harmless the City of MISC.- REFER TO ORD.
Cupertino i'its,jucasts and expenses which PERMIT ISSUANCE 10.00CONST.TAX
may i any ce a uty in consequence of the
\/ gran' gof i r MECH.CONT. LIC.NO. MECH. �[
%
TOTAL TOTAL
signep mea
t Ant/ConUOCtor ate
OFF CE COPY