11069 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 10465
/�U P465 (� • 11069
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
CONTRACTOR'S I ' , ReleE O6-J
N mUTLETS-SWITCHES-RECEP• 10.00/1.00
N,\
C^ � IC.NOQI.JCaO LIGHTING FIXTURES 10.00/1.00
rADD sCTORAPPLIANCES-RESIDENTIAL 4.00
41 1 \ \
PHON PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
/I.[
AvvucANrs
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 /AA
woo LICENSED CONTRACTORS DECLARATION l'V lI-
a it U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G < n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
R wi, Professions Cod (,and asy Ase is in full f ❑ ❑ ❑
2 o m - Date s Lia Num
Q Z H w Date Contmcto nu
m -+
¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
o s D INFORMATION
wIL LL w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
HUOJ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
Q ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
u
O a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w mhe is licensed pursuant to the provisions of the Contractors License /
H z a
Law(Chapter 9(commeacingwith Section 7000),I'Division 3ofthe - r
4 D Business and Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE
¢ f m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(85001):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 400
their 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:'rec Contractor's License Law docs not apply to an owner of
. property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00SO.FT.FLOOR AREA TOTAL ACREAGE
e
himself or through his own employees,provided that such improv - :A
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 2.00
builder will have the burden of proving that he did not build or int- 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 Cl ❑ ❑ ❑
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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a mntractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam 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 ERS'COMPF.NSA'f10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sef-insure,
or a certificate(if Workers'Conifer at,.. Insure or a certified ZONING ENG.SITE NO.
copy
thcrWl''�Ih]$f -�Mb .,�( 8
Policy a R•1Au{i ��l
❑ CerNfie copy is hereby furnished FIRE SPRINK ENERGYT24
Z Z Ccrt L Jed w t t o city 'n,tion division.
F o Applicant ..ff_'� MISC.- REFER TO ORD. YE] N❑ Y ❑ NEI
EC N CERTIFICATED EXF.MP'I'ION FROM WORKERS' PERMIT ISSUANCE - 10.00
FLOOD ZONE A.L.U.C.
CLLLI > (This section LG
need IIT beION completed INSURif he ANCLpermit V for one PLG.CONTE. LIC.NO, TOTAL Y 0 N El Y C1 NE]
CL
� Z hundred dollars(SI00)or less.)
U O I certify that in the performance of the work for which this per, GTY MECHANICAL PERMIT FEE SUMMARY
IL 1- mit is issued, I shall not employ any person in any manner so as to FEE
O W become subject to the Workers'Compensation Laws of California. e..
D.
Date Applicant ALTER OR ADD TO ApE-CH•. 1 5.00 BUILDING
} W NOTICE TO API'LICAN'f: If,after making this Certificate of ISx-
F.. Z_ emption,you should become subject to the Workers'Compensation APPLIANCE \ tQ0 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or his permit shall be deemed revoked. AIR HANDLING UNIT(TO .M:)V 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVEff 10000 C.F.M.) 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.(.'). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Leader's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have mud this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n estate. I agree to comply with all city and county BOILER H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and p
hereby authorize representatives ec this city es enter upon the BOILER-COMP (Over 100,000 STU)SEE FEE SCH. /,5 CSD-o
Above-mentioned property for inspection purposes, MECHANICAL V
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Babilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gr t flhis ermil. ME H.CONT. LIC NO. MECW '
� I OTALN� TOTAL
S t re of Applicant/Confmdor to U
OFFICE COPY 2-111
6%7