11140 i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY C)V
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11140
ADDRESS-,
/- lQ4�-e- � BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S K./ .n PLAN CHECK VALIDATION
NAM �'J OTY. ELECTRIC PERMIT FEE
LPHONE z63-('
NAME
UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
L` ( LI C.NO, LIGHTING FIXTURES 10.00/1.00
r-ONTRACTOR'S h/26PPLI
PEAS NCES-RESIDENTIAL 4.00
A�PESS
SIT HOrvE �{.i PANL10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 2000, PLAN CHECK FEE P.C.NO.
OR
ENGINEER �(� t�f
uc NO SIGNS TRANS. 3.00
ARCH..ESS ENa SPECIAL CIRCUIT 5.00 IT VALIDATION
AODREss
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH. U�J q '�cj y�
ADDRESS F+
SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION City Of Ver t ��
1 mp u I hereby affirm that I am licensed under Provisions Of Chapter 9 ISSUAN E DATE
H Q N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH,
r n% Professions Code, in ty license is in full foueel ) ❑ ❑ ❑ rDl
z o v - License Class s' Lic.Number LV
0 z D Date &-12Z• Contractor
a YE � BUILDING PERMIT
w ¢ OWNER-BUILDER DECLARATION INFORMATION
aoA " MISC.- REFER TO ORD
w3 u h 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
u0a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
� yv� Code:Any city or county which requires a permit to construct,alter,
2 Al 4 0O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- o u requires the applicant]m such permit to file a signed statement that TOTAL PERMIT TO
w $ 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 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
I_ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
in A. by applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred Aollnrs($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,an J 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 docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
.cuts are not intended or offered for sale.If,however,the budding
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 ins- RES IND CON PR Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ 0 0 D
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
contracts forsuch projectswith a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
the Contractor's License aw.
❑ lam exen Sc R.&P,C.I'orlhie WATER HEATER W/VENT 6,00
reason
Owner I Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF-NSA'I'ION DLCLARATION WATER TREATING EQUIP. 5.00
I hereby iffiml Ihal I have in certificate afcoment to slGinsve, ZONING ENG.SITE NO.
or a ccNifica®of Workers'Compensation InsurmsI1e4,Or a cer4lified
copy lherenf(Sec.3800,Lab.C.l.41aP.AT`C IIIUTl�1al-
Policy No. Company
Q ❑ Serlilied copy is hereby famished. FIRE SPRINK ENERGY T-24
Z_ Z Certified oRy Is' fed IIh Ore city inspection division. MISC.- REFER TO ORD. Y N Y C:] NE
Applicant �}}\ \
I- mPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
� - CERTIFICATF;OF EXEMPTION FROM WORKERS'
Lu COMPENSATION INSURANCE 11
PLG.CONTR. LIC.NO. PLG, y� N� YF N❑
d O ('fills .,titin need not be completed if the Permit is for one TOTAL
Z lrendreddollars(SIOO)orless)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEELL FEE SUMMARY
1P mit is issued,I shall not employ any person in any intoner so as to
0U became subject to the Workers Compensation Laws Of California. BUILDING
Dmc Applicant ALTER OR ADD TO MECH. 5.00 _
} ran NOTICE TO APPLICANT: If,after making Ibis Certificate of Ex ALTER
Z_ cmplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION 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. MICROFILM
3097,Civ.C) HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders NailHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address_
I certify that]have read B's application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over10 0BT ISEE FEE SCH. MECHANICAL /(9 0
above-mentioned property for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.' 441211
ER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERM ISSUANCE10.00 - (/V CONST.TAX
may is any way accrue against said City in consequence of the
granli g of this permit, - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signatu a,
IF ate �i `9{E- \9 S-
OFFICE COPY