11476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• ,, BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
aulLolxc
AOO Ess YoR�esi�' I RE Oti, 11476
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
_ OWNER'S PLAN CHECK VALIDATION
NR� �Gi�Trc� 737-y3$ DT . ELECTRIC PERMIT FEE
PHONE
NAMEHAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
uC.No. LIGHTING FIXTURES 10.00/1.00
CON
AooREasTRACTORS PP LIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.QO PLAN CHECK FEE P.C.NO.
OR
NGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR
ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'a MOTORS SEE FEE SCH. �w -
ADDRESS
SRM F. SERVICE CHANGE 20,00 ��/7/rte
w D o LICENSED CONTRACTORS DECLARATION Q •�
rt u I hereby affirm that I am licensed under provisions of Chapter 9 - ISS ANCE DATE
a ii (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Z H N Z Professions Code,and my license is in full force and effect. ( ❑ ® ❑
o 0 m W License Class Lia Number
H Date Contractor
x s BUILDING PERMIT
r[ w
OWNER.BUILDER DECLARATION INFORMATION
jx O e N 1 hereby affirm that I am exem t Iron the COnlruclors License MISC.-
w 3 u y g p permit
to con Professions VALUATION
F g O a' Law for the followin reason.(Sec.7031.5, PERMIT ISSUANCE 10.00 /a —
Code:Any city or county which requires n permit to construct,,also
er ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.DONTR, LIC.NO. ELEC.
O 2 requires the applicant for such permit to file a signed statement that TOTAL ��^ PERMIT TO
d w m he is licensed pursuant to the provisions of the Contractor's License
Hir Law(Chapter 9(Commencing with Section 7000)ofDivision 3 of the 6-"
m o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
BE s-$ the basis for the alleged exemption.Any violation of Section 7031. STORIES TYPE CONSTR.
i ; _ by any applicant for a permit subjects theappliciut too civil penalty ALTER-DRAIN -WATER (EA.15.00
of not more than five hundred dollars(5500)):
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 .00C.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,AREA,COND. 5.00
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 5.00 -- SQ FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided thut such improve.100.
.cuts are not intended or offered 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-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or int, BUILDING USE
Prov for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
. RES IND CON PB ONsr
I,as owner of the property,am exclusively contracting with
I' c sed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Profession Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractods)licensed pursuant to SEWER-SANITARY-STORM EFj.200ftI10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/ 6.00
eason
Owner a fT WATER SYSTEM 5.00
r. ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARAON WATER TREATING E
TIO PJ 5.00
1 hereby affirm that I have a certificate of consent la self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y [] NE] Yo No
~ +n
� CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 U' FLOOD ZONE A.L.u.C.
Lu f COMPENSATION INSURANCE PLG.CONTE. LIC.N0. PLG.
AL /
0- ❑ (This section need not he completed if the permit is for one TOT3 Y❑ NY N
� �
::) Z hundred dollars IS 100)or less)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,I shall not employ any person in any manner so as to
D become subject to the Workers'Compensation Laws of California.
O i Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} h NOTICE TO APPLICANT'. If,alter 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 farthwith comply with FEE
CJ such provisions or This permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.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 pernot is issued(Sec. MICROFILM
3097,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00-
Leader's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Q
Lenders Address ELECTRIC
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 PLUMBING fS
'• •1, ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
creby authorize representatives of this city to enter upon the BOILER-COMP loss,100.000 STUI SEE FEE SCH. MECHANICAL
uhove-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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting�[hisyermfl, y MECH.CONT, LIQ N0. MECH.
\ 1, W [K(/t LI•�Z+2r� '7//7/4 TOTAL TOTAL st/l7
xl Signature of Applicant/Contmcmr Dale `?
/ OFF ICE COPY '