10242 (2) APPLICANT TO FILL ININFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT O e� A r)
(�
ADDRESS oO' 61A+61,
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�/If/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O NER'S
es f�S t� 7�j� OTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
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�ONE a 5-0
rcuAMTRA TORS r' e P OUTLETS-SWITCHES-RECEP 10.00/1.00
7
C .�
/L a o00 Ivew LIGHTING FIXTURES 10.00/1.00
ADDRESSTOR'BY♦ /1 /n APPLIANCES-RESIDENTIAL 4.00
V U1 lD mt PHONE /']/y// PANELS 10.00 DATE OF APPLICATION
ARCNITECT FE
DR /� PANELS (OVER 200 AMP) 20.00 PLAN CHECK E P.C.NO..
ENGINEER/ / /',
SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT VALIDATION
ADOREss ..Si4Nd�e SPECIAL CIRCUIT 5.00 /
oa er .4Ne ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADORES$CT.. ^ � tf ®Jz MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
iQ w I hereby ffff[�m� t i l,aam lice n d under provisions of Chapter 9 ISSUANCE DATE
,a ¢ d fcommcn I�6[YHA eti,--,,��rr��,�yy� f Division 3 of the Business and BLDG. ELECT. PLG. M
H N z Professions C�de y�C�nly in full for
Z
0.- License lass - L55222222"'''"'''"Number
w h w Dale 7�-_Conlmcfor
Q y s BUILDING PERM
Ic a w a OWNF-R.BUILDER DECLARATION
° A ° - MISC.- REFER TO ORD INFORMATIO
w ; H I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
o¢ Lew for the following reason.(Sec.7031.5,Business and Professions
ar a. y PERMIT ISSUANCE 10.00
w Code:Any City or County which requires a permit to construct,alter,
2 C Q O improve,demolish,or repair any structure,poor to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i °°M requires the applicant for such permit to file a signed statement that TOTAL
w b y he is licensed pursuant to the provisions of the Contractors License PE MIT TO
FZr Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
Q Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 ORI TYPE CON R.
dF,_ by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500).1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the I Torture is not
intended or offered for sale(Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,CON D. 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 TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedor offered farsale,If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,Lhe owner- GAS-EASYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or an. . BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ 1,as owner of the property,am exclusively Contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 600 ASSESSOR 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 LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt under Sec. •,B.&P.C.far this WATER HEATER W/VENT 6.00
rCUSam
Owner - Date WATER SYSTEM 5.00 Ace.cATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I.have a certificate of gansenf jo insure. ZONING
or a certif c��_ab�Py�1qf ��kk Cy ,r7cerlil'ial ENG.SITE NO,
copy'hered((sy,1CN'60tS:1.'�j. s/7 G
Pgliyy No.// CompunS'
O a Certified copy is hemb f in ed.
FIRE SPRINK ENERGY T-24
Z Z ❑ Certifie o 's fl he city inspection division. MISC.- REFER TO ORD.
O APPlicanl �s�a y❑ N❑ y E] NF]
Cc'N CERTIFICATE OEXEMPTION PW
ROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.O.
LL > COMPENSATION INSURANCEPL TH, s LIC.NO, PLG.
CL Z (This section need not be completed if the permit is for
nom
/$// TOTAL Y[D NE] Y ❑ NC]
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
O i Dare ApplicantBUILDING
�- W NOTICE TO APPLICANT: If,after making this Certificate of F:x- ALTER OR ADD TO MECH. 5.00
L.. Z emption,you should become subject to the Workers'Compensalion 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CFM.) 6.00 SEISMIC FEE
1 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 HEATING UNIT 100,000 B.T.U.)9.50
Lender's address ELECTRIC
I certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP 10r 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MIS RE ERT ORD.
Cupertino against liabilities,judgments costsand expenses which PER T ISSUANCE 10.00 CONST.TAX I
may in any way accrue egains said City in consequence of the I
gmnfin of this permit MECH,CONT. LIC.NO. MECH.
l_ TOTAL QI
SlgnaNre of Apphcanl/Contracmr API Date 1W 1 GB 3q all' Z� TOTAL /
OFFICE COPY