16409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 16409
ADDRESS
101.rJM,VkLFGCC) noo BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER's PLAN CHECK VALIDATION
rvAME
//rIL�� j'A/�5�'1'11 Q �PA
- QTY. ELECTRIC PERMIT FEE
FNIL-�TH✓g'11 VIV, ,`�-- PHONE
corvrflAcrofls UTLETS-SWITCHES-RECEP 10.00/1.00
NppPMyyE �IC��12�)
W7C V1� Llc.rvo. LIGHTING FIXTURES 10.00/1.
CONTRACTORS APPLIANCES-RESID IAL 4. '
fADDRESS - QQ��� t(� �JQ��//1y/ry���) _
'eq�-MABV (�/ PHONFZ9&/�00 PANELSp DATE OF APPLICATION
ARCHITECT PANELS (OV 2 O 0, PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TR S.
ARC
H.OR ENG. SPECIAL WHO' ' "' PERMIT VALIpATION
ADDRESS
ZIP EMP.METE131PR PO 20.00
APPLICANTS MOTO SI SEE FEE SCH.
ADDRESS Vy1�1
SERV) A 20.00
ro o LICENSED CONTRACTORS DECLARATION ""`� • ' \s.ka-+-P`•'v'-L
a U u 1 hereby affirm pmt I mn licensed under provisions of Chapter 9 ISSUANCE DATE
y aN (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w ro
Z Pfessions Cod d my license is in full for,, nd e h S
z O w License la Io Lic.Number��blL4 ❑ ❑ ❑
ow F w Datc .1��0 Conlractor.QiCa�-
Q BU LDING PERMIT
rc ¢ w¢ OWNER-BUILDER DECLARATION
E
;u 1 hereby affirm that I am exempt from the Contracmr License
MISC- REFER TO ORD INFORMATION
VALUATION 5/FT.
F, LLoa Law for tire following reason.(Sec.7031.5,eorBusiness t locoand Professions PERMIT ISSUANCE 10.00 �a
Code,Ary city ar mu my which stquit re Permit luso issuanLalter,
rt a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO, ELEC 0
T requires the applicant for such permit to file a signed statement that Qp��E►.IOI�I / O 1 TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License Wim- C�
Hie U.(Chaple,9(commencou with Section 7000)ofDivision 3 of the
a Business and Professions Code)or prat he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ f o the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
e. by my applicant for it permit subjects the applicant toll civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more
than it,,hundred dollars(55001.):
❑ 1,as than
of the property,or my employees with wages as BACK F LOW 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,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 does such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve- .
mems are not intended anpfc,cd ltrr sale.lL however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
RES IND CON PB ome,
prove for purpose of salc.l. INDUSTRIAL WASTE INTER. 30.00
❑ 1,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.Und who iLAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects will,a cu)ntraclode)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ to an exempt under St,.-,R.&P.C.for tills WATER HEATER W/VENT 6.00
reason
Owncr [)ate WATER SYSTEM 5.00
ACC.OATE ACG FILE NO.
WORK ERS'COMPENSA NON D17CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Iah.C.).
Policy Na Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is Filed with the city inspection division. MISC. REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ ti❑
W CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.C.
UJ > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. 'PLG.
CL O (this section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ No
0 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of tare work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL i- mil is issued,1 shall not employ any person in any manner so as nil
U become subject to the Workers'Compensation Laws of CaliRmhia.
y Date Applicata ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE '10 APPLICANT': If,after making this Certificate of Ex- _
Z emption,you should hecnmu Rohrer ter m the Workers'Compcnsatmn APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Coda you most Iorthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONS'ERUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.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.Ci,C.), HEATING UNIT(TO 100,000 B.T.U.) 9.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I hove 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 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 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep faultless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnhenls, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acaruc against said City in conscqucmee of the
mntingof Ilu eons MECH.CONT. LIC.NO. MECH.
/t"hDeDz�PAD TOTAL TOTAL
Signature of Ap
/p
-clicantt//Coonnt/ractAor, Date
OFFICE COPY