12006 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 22 Wilkinson006
AODREfOilkinson Ave. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS U PLAN CHECK VALIDATION
-\ NAME O .
• \ A.J. Learn 253-9821 OTY
5 _9821TYELECTRIC PERMIT FEE
PHONE
J NAMEACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Atlas Heating LIC.No 465266 LIGHTING FIXTURES 10.00/1,00
CONTRASESCTOR's
ADDR PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C.NO.
on
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS
zm TEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 •,`/zO / n
woo LICENSED CONTRACTORS DECLARATION `U ✓ ` X v
<Be u I hereby affirm that I am.licensed under provisions of Chapter 9 ISSUANCE DATE
I- 2: w (commencing with Section 7000)of Division 3 of the Business end SLOG. ELECT. PLG. MECH.
rD z Professions Co a y license is in full�68fect. ElEl E3O
xLicen�xi C-lus� Lic.Numb 00 FVr
a OR - O Dale 1'/ _ Contractor �'B
a a,f - BUILDING PERMIT
a ¢ OWNER-BUILDER DECLARATION INFORMATION
It Be
REFER TO ORD
w y I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
H Imo J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requims a permit to construct,alter,
Q io ¢Q Improve,demolish,Or repair any Structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e w
es is licensed pursuant to the provisions of the Contractor's License ���
H 2 i
Law(Chapter 9(commencing with Section 7000)of Division3 ofthc
a o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ 1-$ the basis for the alleged exemption.Any violation o(S"tion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant Loa civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the properly,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 unit 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 docs such work F IXTUR ES-PER TRAP 5.00 56 FT.FLOOR AREA TOTAL ACREAGE
himselfornot hrough
ownemployees,for
provided ever,hat the
improve GAS-EA.SYSTEM-1 6.00
( mems are nor intended or offered for sale.If,however,the bel Wing
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
huilder will have the burden of proving that he did not build or fill- RES IND CON PB Other
prove for purpose of sale.). INDUSTR IAL WASTE INTER. 30.00
C31,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 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 contmct.rx)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY•STORM EA.200ft/10,00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconcent(oself-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy there 19459o.OfR
Policy No. mp. CJ. Allied Pacific
y
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z 0 Certified cpyy.r is filed_ h ulna ty inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y❑ No
O Applicant \.Llati H tl
~ uaPERMIT ISSUANCE 10.00
� CF:R'I'IPICATE EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.c.
DJ _ COh1PE1iNSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
d O (This section need not be completed if rhe permit is for one „F TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollarS(E100)or less.) '
L) O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- 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.
(L Dale Applicant ALTER OR ADD TO MECH: 5.00 BUILDING
} In NOTICE TO APPLICANT: If,after making this Certificate OF17x.
� ? emption,you should become subject to rhe Workers'Compensation APPLIANCE „t�n'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 1 ,OQDC. .M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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. d MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Q
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and - BOILER-COMP(3 H.P.or 100,000 B,T.U.) 6.00
hereby authorize representatives of this city to 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.- REFERTO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against Said City in'consequcnce of the PERM JSSU C 10.00 l0
60
gmnli Of Ibis permit MECH.CON L EC H,
TOTALQ �s TOTAL
Sr nature of Applicant/Contractor, Datc �- '7TOg.7�� 6��
OFFICE COPY