11138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJ CT I Eg FIC TION PERMIT NUMBER
BUIEOINc - APPLICATION & PERMIT 11138
�ro AOORE55� 9yy� �uNGO 8 ti3
�./ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
/J
OWNER'S PLAN CHECK VALIDATION
NAME 1 . ELECTRIC PERMIT FEE
_
PHONE
r
CONTRACTOR'$ - µ
NAMEOSr f/ OUTLETS-SWITCHES-RECEP 10.00/1.00
✓Q� E�LC. LIC.No. 71�y� LIGHTING FIXTURES 10.00/1.00
roNTRACTOR's �T9naY APPLIANCES 4.00
PDORESS '�p(/y
/y C, B (/ PRONE _377JOO/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.06 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. St8M5 TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,66 C) °� PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS EE FEE SCH.
PA D
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARA'T'ION MAT 2
u
u u 1 hereby afllnn that I am licensed under provisions of Chapter 9 -� } ELECTISSUANCE DATE
w< m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H n- Professions Code.' J my license is in full farce and.PO Yf ❑ ❑ ❑
z o m - License Class (C Lie.Number V`l S
o F O Date T-2 CmHractor---;P"-
BUILDING
-;P" BUILDING PERMIT
tE w u OWNER-BUILDER DECLARATION INFORMATION
w3 LL N 1 hereby affirm ilia I am exempt from the Contractor's License MISC.- REFER TO OR
F u_ 04 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
b0 Code:Anycity orcounty which requires a permit to construct,alter,
K s-2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC. /A�^
- C e, requires the applicant for such permit to file a signed statement that TOTAL /V_ PERMIT TO
d w es" he is licensed pursuant to the provisions of the Contractor's License ELL-�
Fii
Law(Chapter 9 f commencing with Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that Ile is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ moo the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONBTR,
n : w by any applicant lot a permit subjects the applicant toa civil penalty
ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).1:
❑ 1,as owner 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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• property who builds err improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himscll' Wthis own employees,provided that such improve
menus are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or uRProvement 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 all- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,an exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the Project IS".7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a conlractcoo licensed Pursuant to SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Tum exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYST EM 5.00 ACC.DATE ACC.FILE NO,
WORKF,RS'COMPIiNSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirot that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.CJM��4�wZQ�
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ) Certified appy is BkJ W(t(I t �edY inspection division.. MISC.- REFER TO ORD. y❑ N❑ Y ❑ N❑
H APPlicant�_ �� ra-YL ,T--
Lr
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LAJa C.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ Y ❑ N❑
d 0 (This section need not he completed if the Permit is for one TOTAL
0 Z hundred dollars($100)or Tess.)
U O 1 certify it,., in lire perl'urmance of the work fur which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
Q_ H mit is issued,I shall not employ any person in any manner w as to
O0 become subject to the Workers'Compensation Laws of California. BUILDING
111 Date Applicant ALTER OR ADD TO MECH. 5.00
} VG'i NOTICETO APPLICANT: If,after making this Certificate of Gx-
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 1Op00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for I 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 Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC '0a6r"
Lender's Address
III I certify thin I have read this application and stale that Om above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county� PLUMBING h' ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
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
may in any way accrue a$$$���mSt j W City in consequence of the
grPERMIT ISSUANCE 10.00
anting oft spermil.A / I - /) MECH.CONT. LIC.NO. MECH.
-- �altl/(/,d� TOTAL TOTAL
Signature Applian t/Co ractor or Date
OFFICE COPY