15681 ArPLICANT TO FILL IN INFgILMATION WITHIN RED LINES - USE LL POINT PEN ONLY
- BUILDING PROJECT IDENTIFIC N PERMIT NUMBER
BDILDING APPLICATION & PEWIT
15681
N
ADDRESS .1 p,
.L.� O 11{ I.IWOL,f pjx BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS/� N pPLAN CHECK VALIDATION
NAME C�'�-G-O �'\ OTY. ELECTRIC PERMIT FEE
. \/ALI.Go tgASHlota 'P��K �.
NTRACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
NAME /�., }�{� 1 y CO,
O x
AIS to+aDt�ioNl�,�N10 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S (40$ APPLIANCES-RESIDENTIAL 4.00
OGRESS
�10o ta0�✓fR1AL �� PHONE 5 a-ant
PANELS O.00 DATEOFAPPLICATIOIN ]
ARCHITECT yyx /'ONJ.( R01�( S PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P;C.,NO.
ENGINEER�,q/1�iJ1'yJ�y4I ApF,ff
111 sec.No. SIGNS TRANS. 3.00
ARCH.OR ENc. V G (2R1Zo SPECIAL CIRCUIT' 5.00 PERMIT VALIDATION
ADDRESS
\0c�1L7 SArITlbrlsLo AV& zIP9 5.4 EMP.METER OR POLE INS. 20.00
APPuCANT'S MOTORS SEE FEE SCH.
ADDRESS
irl., J 1.Q; SERVICE CHANGE 20.00
va
o o LICENSED CONTRACTORS DECLARATION
m v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wG w (commencing with Sermon 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Profes,i..S C.de,a d my license is in full force and eft cl. ❑ ❑
z o m- Licenssyy c] Z� -L Lie Number_7LO y1 11 - El
g z D
Date
-q-P.Si Contractor '
a y E BUILDING PERMIT
CE ¢ w,¢ OWNER-BUILDER DECLARATION
o A MISC.- REFER TO ORD INFORMATION
F
L 1 hereby affirm that 1 am exempt from the Contractor's License
Loa Law for the]'.[]owing reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 vnLUATION S/FT.
� - o Code:Any city orcounly which respenesa permit t0CmnstoFCt,alter,
EE a Q 2O improve,demolish,or repair any sfeclure,prior to its issuance,also ELEC.CONTR. LIC.NO. LED.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of0e /�gL
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ce II o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
O 1,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 olfered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
. menu are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 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 Om.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,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 contractors)licensed pursuant m SEWER-SANITARY-STORM EA.200f1/10.00
the Commclor's License Law. TRACT NO. PARCEL NO.
❑ lain exempt under Sec .B,&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
Wo S,CPAPENS11'ION cDECLARATION WATER TREATING EQUIP. 5.00
I hereby' nm f 0,7�0ti]¢'eT"e��Dlisent to self-insure.
or a cerlifi le of Workers'Compensation Insurance,or a certified 20NING ENG.SITE NO.
copy there f ISee.3800,Lab.C.I V HiQ V
Policy No.. Company��,
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z
2 ❑ Certif- col Is filed v t Ili city Vnspeebon division. MISC.- REFER TO
Applicant V E] N❑ V [D NE]
cw CERTIFICA 'E OF :X[MPTION FROM WORK ERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.uc.
lJJ �_ COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLO. % V❑ N❑ Y❑ IN
CL Q (This section need not be completed if the permit is for one T
Z) 2 hundred dollars IS 100)or tell
L) 01 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT 14E FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to Q
U become subject to the Workers'Compensation Laws of California. BUILDING
Q w Date-Applicant ALTER OR ADD TO MECH. 5.00
} y NOTICE TO APPLICANT: IL after making this Certificate of Ex
-
F ? emption,you should become subject to the Workers'Coin Peroration APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. I AIR HANDLING.UNIT(TO 10=G.F.M.) .488 6
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.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. MICROFILM
3097,C.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COIVIP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representative of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL J
above-mentioned properly 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
�ayny
way accrue against said City in consequence of the PERMIT ISSUANCE
Ming f this perp MECH.CONT. LIC.NO. MECH. --�
[fin 6_Z� 8 TOTAL TOTAL
Isigrodur1W Ap ]Teen/Contractor Date
OFFICE COPY