11923 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FI TION PERMIT NUMBER
D
RUILDREDINGSS /O/ '(3 Wp g APPLICATION & PERMIT 11923
V C�gil( 4 �jV BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S l '4 s�L t F-- PLAN CHECK VALIDATION
.� NAMEAMJ5?AcBhrl U' (Z-HONE QTY. ELECTRIC PERMIT FEE
qA���I aT✓➢
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAnME
tVX21 LIC.No. E0�! LIGHTI NG F IXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
AOOREss .�a� per( �1
Olt _3gV`nve O PHONE 534-012I PANELS 10.00 DATE OF APPLICATION
RCHrtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
O
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00 3
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH. L�
ADDRESS
SERVICE CHANGE-It", 20.00
Foo LICENSED CON'I'RACTOKS UECLARA'I'ION o-/ -YG /4vv � itL+-�! '
u I hereby affirm that I atm licensed under provisions of Chapter 9 ��( q. ' ISSUANCE DATE
N a H (commencing with Section 7000)of Division 3 of the Businessand , BLDG. ELECT. PLG. MECH.
H w z Professions Co an license is in full Ian an ,,[fe 6 ❑ ❑ ❑ ❑
z 0 m - License Class_ Lic.Nunic ,
2 H w Dam -9�you�p�Contraclor. g,p_,IJ[il�(y C11
a YBUILDING PERMIT
re" OWNER-BUILDER DECLARATION INFORMATION
oa" MISC.- REFER TO ORD
w 3 LL N 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
o a Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 10.00 C1
Code:Any city or county which requires a permit to construct,alter,
Q0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. /�Il-rP
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Fzs- Law(Chapter 9(commencing with Section 7000)of Division 3 of the
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ILH the basis for Ilia alleged exemption.Any violation ofSection 7031.$ STORIES TYPE CONSTR.
u ;� by any applicant for a permit subjects the applicant tua Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
M 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.UNITS
their sole curl pensation,will do the work,and the Structure is not
intended or 0ffC,,d 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 thereom 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-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,Ilia owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that the did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business ILAWN 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 LAN SPRINKLERS-OVER 5(EA.) 1.00
Contracts far such projects with a cunimclor(s)licensed pursuant to gEWWER-SANITAR V-STORM EA.200ft/10.00 TRACT N0. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. ,tl.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WO R K IiRS'COM PENSATION DEC LA RA PION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-inmre, ZONING ENG,SITE N0.
or a ce,ificate of Workers'Compensation Insurance,or a certified
nmy thereof(Sue.3800,Lab.C).
"obey No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ V ❑ N❑
Applicant
H vN' PERMIT ISSUANCE 10.00 FLOODZONE at,.u.c.
�
CERTIFICATE Op EXEMPTION FROM WORKERS'
LU >_ COMPENSATION INSURANCEPLG.CONTE. LIC.NO. PLG.
da TOTAL V❑ N❑ V❑ N❑
('This section need not be completed if the permit is for one
0 Z hundred Cert dollars(n tale pe Icss.l
U O I certify that in the perl'unnance of he work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H nhil is issued,I sluall not umPlcyan �rson in an ner so as to �---C�
O Ed becohn�e�shh//1tb��µ5�t�t�othe Workers'Co anon 'for
BUILDING J
UamAP Applicant ALTER OR ADD TO MECH. 5.00
} y NOTI TOu An PPLICAN'I': 1 , I r making this a ifre a of Is
/
Z emption,you Should become subject ID the WE,
Can an lion APPLIANCE 5.00 PLAN CHECK /b Z�
provisions of the Labor Code, you must forthwith co pl with FEE b ---
C,.) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE C J v
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
ilia performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.0*. HEATING UNIT(TO 100,000 B.T.U.) 8.00 C<Z
Lender's Name HEATING UNIT(O VER 100,000 B.T.U.)9.50 ELECTRIC 43
Lender's Address
• I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
infornalion is correct, I agree to comply with all city and countyPLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0008.T.U.1 6.00
hereby authorize representatives of (his city to enter upon the 801 LER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify unit keep harmless the City of MISC.- REFER TO ORD.
Cupertino agm liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any accrue against " City in consequence of the
Counting o rnit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
an u ol'A plic.nt/Contreo I Ie
61 OFFICE COPY