11452 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -VSE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
ADDDIPIGDRESS /�S �� APPLICATION & PERMIT a ���
ADDRESS 100 ! 0 COr-114eN 1
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL!
OWNER'S
LAME E PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
ars /e1 PHONE 9?30KPG
PRCT,E/I rOUTLETS-SWITCHES-RECEP 10.00/1.00
otoard OfAWE Lt..Noff 209703 LIGHTINGFITURES 10.00/1.00
TRACTOR'S
AoaREss 1 r APPLIANCES-RESIDENTIAL 4.00
(A rE �.
� AO 5fi P Sr5»ONE 9JG2 PANELS - 10.00
ORRc»ITEGT PANELS (OVER 200 AMP) 20:00 GATE K APPLICATION
ENGINEER r PLAN CHECK FEE P.C.NO.
LOC.NO. - SIGNS TRANS. 3.00
ARCH.SS ENG. SPECIAL CIRCUIT 5.00
ADDRESS - PERMIFT,�V�L�TION
ZIP EMP.METER OR POLE INS. 20.00 r~�u
NT S
ADDRESSS MOTORS SEE FEE SCH.
•
z SERVICE CHANGE 20.00 ((nn
Cif f �61fo
,02 LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that I am licensed under provisions of Chapter 9
,H4<y (Commencing with Section 7000)of Division 3 of the Business and ISS CE GATE
H 7 2 Pmfessions Code,agd y hCense i5 in full force AA ( BLOG. ELECT, PLG. MECH.
O z'=D License Class 'L[ Lic.Number T O _ O ❑
F a 1.J Date Contractor
¢ ¢ w a WNER-BUILDER DECLARATION BUILDING PERMIT
U INFORMATION
W ;°A-r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H u 0¢ Law for the following reason.(Sec.7031.5,Business and Professions - VALUATION $/FT.
Code:Any city or county which requiresn permit to construct.al ter,
PERMIT ISSUANCE 10.00
¢ ¢6 FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
i O. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X
$ he is licensed pursuant to the provisions of the Contractor's Licenx
I. Law(Chapter9(commencingwithSection7000)ofDivision3oRhe P��--
f z c Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicair fmrapermit subjects the applicant toacivilpenalty ALTER-DRAIN of not more than five hundred dollars(5500).): IEA.) 5,00
❑ 1,es owner of the property or my employees with wages as ggCK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Businessand Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade: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
himself or through his own employees,provided that such improve-
SO.FT.FLOOR AREA TOTAL ACREAGE
mcnts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
❑ I,as owner of the property,am exclusively contracting with
lic13 El
ensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 - ASg,s,,,,PARCELNO.
and Professions Code:The Contractor's Licenx 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM /10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,B,&P.C.for this WATER HEATER W/VENT -
reason 6.00
Owner Date WATER SYSTEM /
1.4.00 �y ACC.DATE ACC.FILE NO.
WORKERS•CI have a ATION DECLARATION WATER TREATING EO 5.00
I hereby affirm that I have a certificate In comm,to or
certified
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Sec.3800,Company
STATy IVNd
Policy N rt Company he/ �1 CC - /� '
O ❑ Certified copy is hereby furnished. // // FIRE SPRINK ENERGY T-24
Z Z Certified col 's filed w`'Ih yfirrgq city' speclion division. edto
CC
APIs cam-. Luar�eAY(iwb> MISC. REFER TO RD. Y Ni] Y'❑ Nf]
� y CERTIFICA EOP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. q
(This section need not be completed if the permit is for one TOTAL ea(, Y 0 N Y i] No
Z hundred dolhux(SIOG)orlcss.)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensalion Laws of California.
.y Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex
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 V FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1C.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 permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 -
Lender's Name
Lender's Ad dress - HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above - VENTILATION FAN (SINGLE) 4.00
•
information n correct. I agree to comply with all city and county ( PLUMBING
ordinances and state laws relating to building construction, and BOILER•COMP 3H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city
above-mentioned property for inspection purpos
s.to inter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
'
(We) agree tso save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against lis ililies,ju ants, costs and expenses which' CONST.TAX
may in any accrue agai said in consequence of the PERMIT ISSUANCE 10.00
granli mmiC MECH.CONT. LIC.NO. MECH.
"t i/ TOTAL TOTAL
Si or of Applicant/C n actor Vate
OFFICE COPY