17815 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER -
BUILDING T Ib•A APPLICATION & PERMIT a-
A..REss ILDING-ELECTRICAL-PLUMBING-MECHANICAL 17 815
OWNERS PLAN CHECK VALIDATION
NAME20I A4 AK C_0SI CI
' 1./-v-1��Y��1aV 1~ I-` fT' OTY. ELECTRIC PERMIT FEE
Flo e�K_ F-s PRDNEr153 %+3
NA /z NTRAc R$ UTLETS-SWITCHES-RECEP 10.00/1.00
��i'/� Lim LIC.No. LIGHTING FIXTURES - 10.00/1.00 -
CONTRA OR's /aDO PPLIANCES-RESIDENTIAL 4.00
A ESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARC ITECT PANELS (OVER 200 AMP) 2000, PLAN CHECK FEE P.C.No.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESSOR
ESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
AANTS
ADOREooREss MOTORS SEE FEE SCH. '
SERVICE CHANGE 20.00 L 11r i• P
,00 LICENSED CONTRACTORS DECLARATION V•+�`-tel
a u w I hereby affirm that 1 am licensed under provisions 0FC�Iy110GIIe 9 7 - ISSUANCE DATE
m G m (commencing with Section 7000)of Division 3 of the BustW a1J , k , 13DG ELECT. PLG. MECH,
H w z Professions Code,and my license is in full force and effect.11
z O T - Licruse Class Lic.Number
Oz Ic o Date - Cantractar P U T E1R
C OoU BUILDING P RMIT
¢ a OWNER-BUILDER DECLARATION
¢o n U INFORMATION
I- I hereby affirm that 1 am exempt from the Contractor's Li, MIS EFER TO ORD
VALUATION S/FT.
F u o J Law for the following reason.(Sec.7031.5,BusinnsaQd Professors „ 10.00 1 - 0
Code:Any city or county which requires a Permit Inca struct,alter, //��//����
s( 0 improve,demolish,or repair any Slructram,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 1 19 L_L_�J
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he k licensed pursuant to the provisions of the Contractor's.License
iii law
(Chapter 9(commencing with Seosion70001 of Division 3 ofthe .-
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE _
s i v
¢ H $ the basis for the alleged exemption.Any violation oocion]OILS STORIES TYPE CONSTR.
to.
o ; _ by any applicant fore permit subjects the applicant toes.civil penalty
of not mom than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER IEA.15.00 v-
❑ 1,as owner of she protucay,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00 7J
Code:The Contractors License law don not apply to an owner of ✓
.
property who builds or improves thereon,and who Ines such work FIXTURES,PER TRAP 5.00 Sa FT.FLooRAReq To AL ACREAGE -
himself or through his own employees,provided that such improve- la-
ments
mproves � [TQ�
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC-4 OUTLETS 6.00 )'^ U2
or immT
pr
cmem is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200 'T V
builder will have the burden of proving that he did not build or int - . - . .
- BUILDING USE
Prove for purposeofsaleU. INDUSTRIAL WASTE INTER. 3000 R�,E-5/IND CON PB Omar
❑ I,as owner of the progeny,am exclusively contracting with . L1J ❑ ❑ ❑ ❑
licensed contractors to construes 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 mat 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 SEWER-SANITARY-STORM EA.2001t1 10.00
the Contractor's License Law. 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.DATF ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby of firm that 1 have a certificate of consent to sel Ginsom, qq rrT�
or a certificate of Workers'Compensation Insurance,or a Certified ✓'1 ZONING ENG.SITE NO.
copy therrof(Sec.3800,Lab.C.),
Policy No. C 1)panY
O O Cenitied copy' emby furnished. FIRE SPRINK ENERGY T 24
F O App Certified co is Fled ,with ci/Tspectmrr division. MISC.- REFER TO ORD. Y N Y N
��(/J/L/}- ❑ ❑ ❑ ❑
2y . C, ICATI?01'IiXE\ NERON ORW RRS' PERMIT ISSUANCE 10.00 IL FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. - of(] Q Y❑ NE] Y ❑ NE]
Z (This section need not he completed if the Permit is for one TOTAL
hundred dollars IS 100)or lest)
U O l,cenify that in the performance of the work for which this ler- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. f-���
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING F-kU
} to NOTICE 'f0 APPLICANT. If,after making this Ccrtillearc of Cx- rye+
Z emption,you should become subject to this Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Ichor Code, you must forthwith comply with FEE
U such provisions or fits Perinit shall he damned revoked AIR HANDLING UNIT(TO 10=C.F.W 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE g��3
1 hereby ufF. that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this Feunif is issued(Sao. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
HEATINGUNIT(OV ERIDO,000B.T.U.)9.50 ELECTRIC 4105
dT
Lender's
I certify that l have rend This application and state thin file above VENTILATION FAN (SINGLE) 4.00 tlk-
information is erred. 1 agree t.comply with u11 city and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-CONP(3 H.P.or 100,000 B.T.U.) 6.00 41
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL q ��
above-mentioned property for inspection purpnscs.
(We) agree to 've, indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino alai t Iabilitics,judgomnts, costs and expenses whidt CONST.TAX
noy in any uccnm lµ st 'd Cit in conscgt cc ot.thc PERMIT ISSUANCE 10.00 12 i 2.7
ranting. PcnpiL' MECH.CONT. LIC.NO. MECH. ' a �L
/
TOTAL qDr TOTAL l `Y
u of Applican Contractor DJIC 4
OFFICE COPY