11532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING 1000 o :-z- D Z, APPLICATION & PERMIT 11532
ADDRESS
�3[< r� TI�V e.� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
rvamE �p OTY. ELECTRIC PERMIT FEE
NCaCAK.�J PHDNE
CONTRACTOR s� UTLETS-SWITCHES-RECEP 10.00/1.00
NAME O
S�0&IQV60LA�) �LI,C".lN f LIGHTING FIXTURES 10.00/1.00
CoNaflac*OR's//� x ! dims e PPLIANCES-RESIDENTIAL 4.00
AooREsi/n 7
r 17r PHONE,74 QW1 PANELS 10.00 DATE OF APPLICATION
ORCM]rlicT//•1 ,1F PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER /�,.V W � tm&-edpA
LIC.NO. C 40-2-Ir SIGNS TRANS. 3.00
ARCH.OR ENG. / SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS l,� -Q E.CCsµ/a✓o
OAI..T ZIP ITEMP.METER OR POLE INS. 20.00 �---J
ADDREr
SNS MOTORS SEE FEE SCH.
sJ A-IME' S ISERVICE CHANGE 20.00
w
02 LICENSED CONTRACTORS DECLARATION
W
a u I hereby affirm that I am licensed under provisions of Chapter 9 01 LSSU CE GATE
v,C % (commencing with Section]000)of Division 3 of the Business and LECT. PLG. MECH.
F m z Professions Code,and my license is in full IincyWrl}IsFWd�)J ❑ 1n� ❑
z oo -. License Class Lic.Number- J T
a y Date Contractort/Q_5�
m a OWNER-BUILDERDECL//ATTINFORMATION
RATION ILDING PERMIT
rc w u
F
w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
.. 0 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 oVALUATION $/FT.
� - V, ICode:Any city orcounty which requires a permit to construct,alter,
¢ rt¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC. /OQO
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pennant to the provisions of the Contractor's License /
I-z }
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe E/✓l OL r// ���`✓'¢70
a UMBING PERMIT FEE
Business and Professions Code)or that he is exempt therefrom and DTV. PL
E i o
H $ the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES E CONSTR.
d ; by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(85000.):
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC-GROUP RES.UNITS
their ole 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 or improves thereon,and who(toes such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare notintended oroffend for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will hum.the burden of proving that h . . .
e did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7744,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 ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contructoos)licensed pursuant to
the Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Se,.-.B.&P-C 1'o1 this WATER HEATER W/VENT 6.00
nalmt
Owner Date WATER SYSTEM 5.00 ACC.DATE ACO.FILE NO.
WORKF-RS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, - ZONING ENG.SITE N0.
or a certificate of Workers'Compe 'tion dC�rP0*!,4certificd
copy the $0 .0 I. /Y 1 `/,CrS
Policy N6�
Q ❑ �e Oilied copy is hereby(u shed. FIRE SPRINK ENERGY T 24
gl"Ccrtificd copy filed with the city inspection division. MISC.- REFER TO ORD. y❑ N❑ Y ❑ N❑
F p Applicant- IC'I - erd$t1i1�
jry CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 PLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
Dare Applicant ALTER OR ADD TO MECH. 5.00 19
} Go NOTICE TO APPLICANT: If,after making this Certificate of Ex
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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DMC.F.M.) 6.00 SEISMIC FEE .ss,
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of We work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that 1 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 state laws relating to building construction, and
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 harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in cons luenco of t e PERMIT ISSUANCE 10.00
granting this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 3U
ignaturc of Ap ant/Contruclor I
OFFICE COPY