8260 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOREss 10592 3 h 8260
BUILDING - ELECTRICAL'-PLUMBING-MECHANICAL
OWNEH'6 nC -
AM 1�-q `1 OTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
PN N
ONTRACTOR'S
AE OUTLETS-SWITCHES-RECEP 10.00/1.00
�T) � uc.No LIGHTING FIXTURES 10,00/1.00
CONTRACTOR'S W�� IN , I
ADOREsv o ,'1 APPLIANCES-RESIDENTIAL 4.00
Izz PHON 4 PANELS 10,00 OATEOFAPPLICATION
one Nlracr - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No. SIGNS TRANS. 9.00
ADDRESS ENG. $PECIALCIRCUIT - 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 - is
AMOTORS - SEE FEE SCH. y
ADDRESS DRESS
SERVICE CHANGE 20.00
OO o LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30,00 l
a u u 1 hereby affirm that I am licensed udder provisions of Chapter 9 ISSUANCE GATE
rz w leommuncing with Section 7000)of Division 3'of the Business and
w a n BLDG. ELECT. PLG. MECH.
r D z Professions Carl fond-s t "cense is in fall fop ❑ I,jWi�l
f-o i=W Licen. las Lie.Num e -
Date Contracl0hem
a y BUILDING PERMIT
rc ¢w a OWNER-BUILDER DECLARATIO
O A INFORMATION
xx ; LL a 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
FUO J Law for the following reason.(Sec.7031,5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION - $/FT.
Code:Any city or county which requiresa permit toconstrucl,alteq
ce ¢< 0 improve,demolish,or repair any structure,prior to it$issuance,also ELEC.CONTR. LIC.NO, ELEC.
D
w requires the applicant for such permit to file a signed statement that TOTAL ��eora,TrtO
-' $¢w rre is licensed pursuant l0 the provisions of the Contractor's License
rzr Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r $ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
u ; by any applicant for a permit subjects the applicant to a civil penally - ALTER-DRAIN St VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW 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,COND. 5.00 -
Corle:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are throngot intended or offered employees,
sale.provided
thathowever,the building GAS-EA.SYSTEM-1 1NC.4 OUTLETS 8.00
or improvement is sold within one year of completion•the owner-
builder will have the burden of proving that he did not build or ire- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). ' INDUS TR IAL WASTE INTER. '30.00 RES IND CON PB Oer
❑ 1,as owner of the property,am exclusively contracting with m0 ❑ ❑ 0 ❑
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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ftI10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I am exempt under See..,B.&P.C.or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACL.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE N0.
or a certificate�of Workers'Compensation Insu�r•ance•or a1 certified
copy Ihe/pfs(Y�ssD11
PolicyJ\
0 . ❑,f a'Ii0 opy is hereby,f ni bed. FIRE SPRINK ENERGY T-24
Z Z d( Ce if I < h Y Q^n�1v�rs-loe.
O Applican !-1>� MISC.; REFER TO ORD. Y❑ NO Y ❑ No
~ rn PERMIT ISSUANCE. 10.00
LU - Cli PICCOM E EXEMPTION Pit 1 WORKERS' _ FLOOD ZONE A.L.U.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. -p LG. -
CL'Z (This section need not be'completed if the permil,is for one TOTAL V N� V C2 N[]
hundred dollars'(81001 or lcssJ
U O I certify that in the performance of the work for which"his per- OTV. MECHANICAL PERMIT FEE, FEE SUMMARY
LLH ant is issued,I shall not employ any person in any mannerso as to . ,
0 W become subject to the Workers'Compensation laws of California
Date Applicant' 'BUILDING
a ALTER OR ADD TO MEC-. 5.00
} m NO1ICemptio Ii TO APPLIshould become
If,after making"his Certificate sa Ex-
�'2 er vision you the L become subject to the Workers'Ccomply with APPLIANCE 5.00 PLAN CHECK
. provisions io the Labor Code, you must drevoke comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT( Op00'G,. .00 ,
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PIWCF.M.) 6.00 • "SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WI Pt0 T.)UPpef II1900
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ,C,). HEATING UNIT(TO 100,000 B.T.U.) 8.00z
Lender's Name
Lcndcr's Add.. HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC '..
I a"r"il"y that I have read this application unit state that the above VENTILATION FAN-ISINGLE) 4.00
info...nit, is correct. I agree to comply with all rslrund county BOILER-COMP(3 H.P.or 100,000 B.T.U. 0 PLUMBING
ordinances uis corre laws relating in building"Con51fand county,ancl I
hereby authorize representatives-o1' this city (counter upoyi ' BOI'LER-COMP(Over m 100,000 $• ESC MECHANICAL
above-mentioned property for inspection purposes:
(We) agree to save, indemnify and keep harmless the City of MISC.- ( LH TA ,
_ lid
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE .00 CONST.TAX
cildmay in any way accrue against said City in consequence of the
ra Of this ¢ It �x MECH.CONT. LIC.NO. MECH.
/I 1 \( \ ` 1 .I TGTA � TOTAL
: ueof Applicant/Contractor V ♦ w.e-fr'inlY
OFFICE COPY