4111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
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APPLICATION & PERMIT
E55 4111
• BUILDING n4-
A R
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
ULER's /xIl PLAN CHECK VALIDATION
N E lti/ OTY. ELECTRIC PERMIT FEE
r Wb PHONE egg
CONTRACTOR
ry E q OUTLETS-SWITCHES-RECEP 5.00/1.00
allco / uc No LIGHTING FIXTURES 5.00/1.00
ONTRACTOR'S
aDDss 0 - - APPLIANCES-RESIDENTIAL 4.00
Ot PHONEPANELS 5.00 DATE OF APPLICATION
OPCHITEC SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc D. SIGNS TRANS. 3.00
ARCH.ORE - PERMIT VALIDATION
AOOREs : / R 0 SPECIAL CIRCUIT '5.00
CLQJ l/..Rw �.1�A1 O ZIP TEMP. METER OR POLE INS. 15.00 pA' "
APPLICANTS MOTORS SEE FEE SCH. �1
ADDRESS
SERVICE CHANGE 10.00 G 2 •,�/ ,3
O o o LICENSED CONTRACTORS DECLARATION
a 0 w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
t, ¢n G IS PLG. MECH.
H D i Professions Code and nemse is in full fors ad e L ❑ ❑ ❑
License�fpla .Lia.Number r0
•o r O Date4 171 Conitlrcior �.1_ e-1---
a y E I. BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
S ¢ w O INFORMATION
X ;LL t- I hereby affirm that I'am exempt from the Contractors License MISC.- REFER TO ORD
ut VALUATION $/FT.
FU0< Law forthe following reason,(Sec,7031.5,Businessand Profesio
s n s. PERMIT ISSUANCE 6.00 /
fw0
4 Code:Anycity orcounly whichrequiresapeimitto consln¢Lalteq
¢ ¢ ¢ O improve,demolish,or repair any slnlnNre,prior m its issuance,also ELEC.CONTR. LIC.N0. ELEC.
d D ¢ requires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision3 ofthe SE-,qVICE '8J,5 If,Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
f i o
¢ I- $ the basis for the alleged exemption.Any applicant
fo actimn 7031.5 STORIES TYPE CONSTR.
by any ouretha fora permit subjects the toucivil penalty ALTER-DRAIN -WATER(EA.) 4.00 a
of not more than flue LundreA'dollars 185001.1:
O 1,as owner of the property,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
intended or offered far sale (Sec. 7044, Business m,11 Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
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 sD.FT.FLOOR AREA roraL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedl'orsale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00 3.3s
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or iIn- iGAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CDN PB Other
Cl 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec, 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply 3// _ ��
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00 ro
contracts fur such projects with a contractions)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
n I aan exempt under Sec' ,IL&P.C.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMNiNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirms that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Conrpens: Ion insurance,or a certified
copy thereof(Sec.3800,Leb.C.l.' /!/�
I'o icy
Nn. Company:;A �q
crtil'iedco Is here nu Ie �!�/.Lr/ !n FIRE SPRINK ENERGY T 24
O APPniCe'tifi• I v is flay it L-f11Y f1f enlm'Yision. - MISC.• REFER TO ORD. v N v N
❑ ❑ ❑ ❑
cc T CERTIRTI I�CATE OOFFEXEMPTION FRNt W( K14RS, PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > CONIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
M. 0 (This section need not be completed if the permit is for unc - TOTAL Y❑ NEI Y❑ N❑
Z hundred dollars($100)orless.)
U O 1 certify that in the performance of thework forwhlch this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL H' mit is issued,1 shall not employ any person in any manner sn as to
U become subject to the Workers'Compensation Laws of California. 9
Q Wa . Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING s33 00
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
propermit
of the Labor Code, you must forthwith comply with FEE
U such provisions or this shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
.CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 9 8'O
I hereby affirm, that there is a construction]ending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CU. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NameHEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN_(SINGLE) 3.00
information is correct. I agree to comply with all city unit countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1'4.00
•� hereby authorize representatives of this city to-enter "Pon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORO. ^'3 2
Cupertino against liabilities,judgments, costs nit expenses which PERMIT ISSUANCE 3.00 CONST.TAX d/
may in any 'y nwme otos said City consequent ofIPL,
granting of sllgrmiLMECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
Si at eof Apple t/C nlra Dat
OFFICE COPY