18065 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDS L r, APPLICATION & PERMIT 1806
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
rra'/n YI � r OTY. ELECTRIC PERMIT FEE
V C.., I vHON (((J JG
CO TRACTORS
N E �/ OUTLETS-SWITCHES-RECEP 10.00/1.00 p '
5 •D. e37y57 LIGHTING FIXTURES 10.00/1.00 PAID
;o FtIADTDR'#Vo S.C/ C;V-n�w/n v APPLIANCES-RESIDENTIAL 4.00
ADpRE �'✓" . �l �.17 1991 _
PANELS 10.00 EOF APPLICATION
ARCHITECT PLAN CHECK E P.C.NO.
OR . / PANELS (OVER 200 AMP) 20.00 Of
CUVt�fI
ENGINEERN
LIC.NO. SIGNS TRANS. 3.00 .C��y
ADDRESS END. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
! it EMP.METER OR POLE INS. 20.00
APPLICANT
I MOTORS SEE FEE SCH.
AT Qy,y/p
SERVICECHANGE 20.00
waz
,00 LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that I am licensed under provisions of Chapter9 ISSUANCE DATE
v, Q vWAi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 y z Professions Code nd Y I' ensc is in full fo f ❑ ❑ ❑
z o m - Licens las_ Lic.h'umhcr u
o m r Date ComractorqfB 6,z- I
Q w a OWNI'R-BUILDER DECLARA'FICI I ! P U II � l BUILDING PERMIT
- a'0 MISC.- F O I INFORMATION
X ; u_y 1 hereby affirm that 1 am exempt from the Contractor's License
LL a 4, Law fur the following•reason.(Sea 7031.5,Businessand Professions VALUATION $/FT.
- PERMIT ISSUAN I
Code:Any city or county whiny structure,
permit toconstruct,,also
au r Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC.
o B, requires the applicant for such permit to File a signed statement that TOTAL
he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Hii Law(Chapter 9(commencingwith Section 7000)of Division 3ofthc
E i o Business and Professions Code)or that he Sexempt therefrom and GTY- PLUMBING PERMIT FEE
21o thebusisfor the alleged rxamplicen.Any violation of Section 703 L5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hmW rod dollars(S500f):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.urvlTs
their sole compensation,will do the work,and the structure is not
intended or offered I'or sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors 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 SO.FT.FLOOR AREA TOTAL-ACREAGE
himself re through his own employees.provided that such improve-
noent is old or within
for ar o If,however,the the ow holding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
buildcr will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting withEl El El El El
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 Contractors License Law does not apply
to an owner of property who builds or improves Hlercon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contruc6 for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ [am exempt under Sec. ,B.&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK t;RS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm otat I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance c Ificd ZONING ENG.SITE NO.
copy Theruf Sec.3800,LjIb.C.I.
sec
Policy N� '�'Cmlrr./ny /
0 F❑F�� Certi i d ' py is herebby lurnlsJJ511
Z Z I* Certif Y• p - j1ed�C`11C' city inspection division. FIRE SPRINK ENERGY T 24
F• O Applicant - MISC.- REFER TO ORD. YF-] N❑ Y ❑ IN
to CE RTI I% I'li OF E-X 1:M PT ION PROM WO RK Ii RS' PERMIT ISSUANCE 10.00
F LOOD ZONE A.L.U.C.
CL ❑ (This uttidn eOJ1PFN bATeOh'plh,S�RANCIiI L.nnit is for oro• PLG.CONTR. LIC.No. IOTA ,
L0Z YO NF] Y [] NE]
So
C..1 O hundred dollars(need or less.)
I certify that in are perforumnce of the work for which this per- GTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers Cone nsution Laws of'Califurnia.
D. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} b NOTICE. TO APPLICANT. If,after making this Certificate of Ex-
♦- 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith vomply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10ACC.F.M.) 4.00 FEE
CONS"f RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby afl'irnt 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 100,0008.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 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
ordinances n cornet. 1 agree to comply with all city and county PLUMBING
ordinances a,rI state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.1 6.00
hereby enti o ed roperty tarries of this city to iota upon tlrc BOILER-COMP Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harnilcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
nay N any ay acini• against Said City in cca,,ucnce of the PERMIT ISSUANCE 10.00
res gOftt permit / MECH.CONT. UL.NO. MECH.
p�1 �9/ TOTAL TOTAL2
Signa eof Ap icaSD%O,ntr or Uatc
OFFICE COPY