6300 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE'BALL POINT PEN ONLY
<' BUILDING PROJECT IDENTIFIPERMIT NUMBER
BUILDING APPLICATION & PERMIT
j aooREss 10158 .U.GI' 6 3 0 0
7�]4TION
DING - ELECTRICAL-PLUMBING-MECHANICAL o3cofar wNAMERa��V.I- ny PLAN CHECK VALIDATION`, ELECTRIC PERMIT FEEVONE
ONTR
[NAME
�y OUTLETS-SWITCHES-RECEP 5.0011.00
VF gz41?,IG '
,C, O. 155171$ LIGHTING FIXTURES •-
f-GNTE R'
40.DT i*E
C4/J03) -sG PPLIANCES-RESIDENTIAL 4.00 11 -512.8 PANELS 5.00 DATE OF APPLICATION
ORRCHrtE - - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
A.C..
OCiss ENG - SPECIAL CIRCUIT 5.00 _ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESa. - MOTORS SEE FEE SCH. J
I SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
< U I hemby'affirm that I-am licensed under provisions of Chapter 9 - ISSUANCE DATE
nam (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MELH.
F N z Professions Code, I' y license is in full force a cl ❑ ,❑ ❑
z0 i'"o License G1a,,S5SS, Lic.Number OCT 2 G 198a
Date IES Contractor
a m5 BUIL G PERMIT
¢ ¢w OWNER-BUILDER R-BUILDER DECLARATION INFORMATION
w ;LL H I hereby affirm that I am exempt from the Contractor's License MISC.- ORD -
F a w J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 �- VALUATION S/FT.
m� Code:Any city or county which requiresa permit to construct,Sher,
y
a, 2 Q 00 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR: LIC.NO. ELEC. W
wO u requires the applicant for such permit to file a signed statement that TOTAL �/ PERMIT TO
he is licensed pursuant to(lie provisions of the Contractor's License EL�7e
F z Q' Law.(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
4 0 Business and Profcsslom Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢H C. the basis for the alleged exemption.Any violation of5eclion 7031.5. STORIES, TYPE CONSTR.
a;m by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN IEA.14.00
of not more than five hundred dollars($500).): -
❑ 1:as owner of theproperty,or my employees with wages as BACK FLOW PROTECT.DEVICE. 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
it intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
9-s 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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
memsarcnotintendedooffered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,lite owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
buiNer will have the burden of proving that he did not build or im-
Y RES. IND CON PB Other
prove mar purpose of sale.): INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ El. El ❑
licensed contractors m construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractorts)licensed pursuant to -
the Contract^r'sLicense Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO, PARCEL NO,
❑ 1 am exempt under Sec. ,IL&P.C.for this WATER HEATER W/VENT 4,00
reason
. . owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
Ihereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a cerlificam of Workers'Compensation Insurance,or a certified
copy them�Sf., �
1'DNa ¢ tyC.4IqCIFI(i
O ❑ Ceniied Copy is heeby
_
furnished. FIRE SPRINK ENERGY T-714
Z Z;' �CertiOed cap Is feQ w' tie Ci ns cion division.
O Appll,mo st4f,l �1d I r MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
M CERTIFICATE OF EXE-MPTION FROM WORKERS' PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.U.C.
LU COMPF-NSATION INSURANCE PLG.CONTR. LIC.NO. - PLG.
d O ' (This.section need out be completed if the permit is for one TOTAL Y;❑ N❑ Y ❑ _IN
Z hundred dollars(5 100)or Iess.)
U O 1 cerlity that in lite performance of the work for which(his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to
U becom•.@ cc the Workers pe �t Lawso��a'f nia.
0 i Dnlc_I1�App1'cant Y;�`'`� ALTER OR ADD TO MECH. - 4.00 BUILDING
} m NOTI_CE TO TO APPLICANT: If,after making This Certificate of Ex-
�.? emption,you should become subject to the Workers Compensation APPLIANCE, 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE,
V such provisions of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE
yr
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) - 2.00
30 ,Civ.mance of the work for which this permit is issued(Sec. MICROFILM
30ader',Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 _
Lender's Address ELECTRIC
I certify that I have read this application and state that the above I VENTILATION FAN (SINGLE) 3.00 - -
information is correct. 1 agree(o comply withall city and county - PLUMBING
ordinances and state laws relating to building construction, and 'BAILER-COfV1P(3 H.P.Or 100,000 B.T.U.1 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCM. MECHANICAL
(We) agree to s.m indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costs and expenus which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue,against said City in Consequence of the
grout of In per MECH.CONT. LIC.NO. MECH.
O j6 TOTAL TOTAL
Signaluroo Applicant/Contractor
Uale
OFFICE COPY