11762 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY
BUI LDI NO PROJECT I DENT[FICATION PERMIT NUMBER
BWLGINc APPLICATION & PERMIT
ADDREB 1S3 y141� nR . 11762
OR- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER 4�p PLAN CHECK VALIDATION
NAME D�.I c "/��' -73 CC7��g-3 QTY. ELECTRIC PERMIT FEE
to PHONE
7._1 CONTRACTORS 0 OUTLETS-SWITCHES-RECEP 10.00/1.00 Q -
NAME
LiC.NO. LIGHTING FIXTURES 10.00/1.00 CONTRACTORS
's
`D
co DIRESS ORAPPLIANCES-RESIDENTIAL 4.00
O
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.rvo. SIGNS TRANS. 3.00
ARCH,ss ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT S MOTORS SEE FEE SCH.
ADDRESS
.sq•M 0i SERVICE CHANG 20.00 14_/A0
Foo LICENSED CON'FRAC'I'ORS DECLARATION I /
<u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ;) ISSUANCE DATE
Q
se A, (Commencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions Code,and my license is in full force and effect y ❑ ter. ❑ ❑
z 0[%, - License Class Lie.Number
-
2 City of CupertinoC
m 1- ° Date C
w ontr:¢lor BUILDING PERMIT
Q y IS
F a w a OWNER-BUILDGR DECLARATION INFORMATION
; OMISC.- REFER TO ORD
e. I hereby affirm that I am exempt from the Contractor's License
LLo¢ Law for the following reason,(See.7031.5,Businessland Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
i �f Cade:Any city or county which requiresa permit to construct,alter,
O
C cwa ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. d!
IS
requires the applicant for such permit to file a signed statement that TOTAL �� PERMITTO
o
a w m he is licensed pursuant to the provisions of the Contractor's License �r
Fii Law(Chapter 9(commencing with Section 7000)of Division 3 of the
F, o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5,00
of not more than five hundred dollars($500).1:
1,as owner of[lie property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4,00
lh it sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 bolds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 42 FT.FLOOR AREA TOTAL ACREAGE
himself Or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or unprovement 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 lie did not build or im- IND CON PB Omer
prove for purpose ofsale.). INDUSTRIALWASTE INTER. 30.00 RES RES
❑ E as owner of the property,am exclusively contracting with IK
licensed contractors to construct the project(Sec.7044,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 properly who builds or improves thereon,and who LAWN SPR I N KLERS-OV ER 5IEA.) 1.00
con tracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.20th/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner LA7. WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate oFcor,ert to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y N� Y 0 NEI
Hy PERMIT ISSUANCE 10.00 FL000 ZONE A.L.U.C.
CC CERTIFICATE Olr EXEMPTION PROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q' O (This section need not be completed if the permit is for one TOTAL Y N❑ N�
D 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 mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
M.
to nate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making HIS Certificate of Ex-
H ? 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 he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
.3097,Civ.C.).
Lender's NudeAZI dr-0
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 7`
I certify that I have read this application and slam that(lie above VENTILATION FAN (SINGLE) 4,00
• information is correct. I agree to comply with all city and county g01LER•CDMP13 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(Ova,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 ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting fth' per il. MECH.CONT. LIC.NO. MELH.
W, � TOTAL TOTAL
Signature of Applicant/Contractor Date
Orrica COPY