10720 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECTI E TFICA O PERMIT NUMBER
B ILOING II o' APPLICATION & PERMIT
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/ gDDRESUAIEerD�f I r G
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME _ .�fJN° a QTV. ELECTRIC PERMIT FEE ' `'
I .� CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAM JP V471VffV LIC.No. I_1806 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
AD KESS L fQ�1111''n 1(�`/�
��% &DPHONE l 1 /( 1 PANELS IO.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP. METER OR POLE INS. 20.00 p
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 1 20.00
0 0 o LICENSED CONTRACTORS DECLARATION a
a v u I hereby affirm that I am licensed under provisions of Chapter') ISSUANCE DATE
vHi< v6i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z Professions Cod nd my license is in full lorcl�yBl�fke�ry ❑ ❑ ❑
Z o,n - icense Cl Lic.Number 10-f _f-
Q Z r° U3tc Contractor. J A N 10 19t+�i
a y s J BUILDING PERMIT
¢ ¢w¢ OWNCR-BUILDER DECLARATION INFORMATION
O MISC.- F D
wLL 1- 1 hereby affirm that I am exempt from the Contractor's License VALUATION
woto Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 l0
t W LI Code:Any city or county which reyuiresapermit to construct,alter,
¢ ¢ Q 40 improve,demolish,or repair any structure.Ilio,to its issuance,also ELEC.CONTR. LIC,NO. ELEC. Z It
O u requires the applicant for such pen.it to file a signed statement that TOTAL V V PERMIT TO
w m he is licensed pursuant to the provisions of the C.Irmetoi s License n
Fzr
Law(Chapter 9(commencing with Section 7000)Of Division 3 ofthe
i 4 o Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 703 t.5 STORIES TYPE CONSTR.
ew. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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 offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00
Code:The Contractor's License Law does not apply to an owner of SO.FT.FLOOR AREA TOTAL ACREAGE
himsell'or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTL
marls are not intended or offered for sale.If,however,the building '
or improvement is sold within one year of completion,the Owner GAS-EA.SYSTEM-OV EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build Or int- RES o CON PB Oma,
prove for purpose of sale.). INOUSTR IAL WAS INTER. 30.00 - ❑ ❑ ❑
O 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPR IN RS- 1 INC 5 V.B. 6.00 ABBE ORSPARCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner Of Property who builds or improve,therron.and who LAWN SP KLERS-OVER 5(EA.) 1. 0
contracts for such projects with n contractorls)licensed pursuant to
the Contractor's License Law. SEWER ANITARY-STORM EA OOft/10. RA rNO. PARCEL No.
❑ lam exempt under Sec. .B.&P.C.for this WAT HEATER W/VENT .0
reason
Owner Date W ER SYSTEM 0 ACC.DAT ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING ECAJ. Ob
I hereby affirm that 1 have a Certificate ofc.H,elt to self-insure. / ZO rvG ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified 11 n
copy thereof(Sec.3800,Lab.C.). is F G•
X Policy No. Company
O O Certified copy is.hereby famished. IRE SPRINK ENERGY T-24
Z 2 -L Certif d copy s Bl d WWi10 the ity inspection division. M S EFER TO ORD. y ❑ N❑ y ❑ N❑
O Applicant {-E RI rl
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUA CE 10.00 FLOOD ZONE A.L.U.c.
W >_ COMPENSATION INSURANCIi PLG.C NTR. U 0. PLG.
a0 TOTA V❑ N❑ Y❑ N❑
(This section need not be completed if the permit is for one
� Z hundred dollars(SI00)orless.)
U O 1 certify that in the performance of the work for which this per- QTAr IT FEELL FEE SUMMARY
I- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT'. If,after making this Certificate Of lix-
F Z emption,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 be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCDON LENDING AGENCY AIR HANDLINGUNIT(OVER 10SWC.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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
.Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC aQ C-�
Lender's Address
I certify that I 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 BOILER-COMP(3 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 (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree In save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against abilities 'udgmenls, costs and expenses which CONST.TAX
may wa ecru Inst smd City in Cori nee f the PERMIT ISSUANCE 10.00
gr h go is nit. MECH.CONT. LIC.NO. MECH.
!//��g�j TOTAL TOTAL
'gnature of Applicant/Contractor Uae s