11798 (2) CL APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION &-PERMIT 798
ADD �'
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER's PLAN CHECK VALIDATION
•� NAME QTY. ELECTRIC PERMIT FEE I
PHDN 3
CONTRACTOR'S q UTLETS-SWITCHES-RECEP 10.00/1.00
, N E ]AI A An h.11011
f4 . LIC.N LIGHTING FIXTURES 10.00/1.00
CONTRACTOt'S - - APPLIANCES'-RESIDENTIAL 4.00
as
PANELS
D 10:00 DATE OF:APPLICATION
ARCHITECT T►1(•E PANELS 200 AMP) 20.00 ,?LAN CHECK FEE P.C.NO.
OR `l�/J
ENGINEER
uc.ND.' SIGNS TRANS. 3.00
AFDH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
' EMP.METER OR POLE INS. 20.00
zlv hi /$jAA
APPLICANTS i '. MOTORS - SEE FEE SCH. Y
ADDRESS -• '
SERVICE CHANGE -20.00 MAR 2.. p
w O o LICENSED CONTRACTORS DECLARATION 19Q7
a u G I hereby affirm that 1.am licensed under provisions of Chapter 9 - Q&IIIIII DATE
as a% (commencing with Section 70001 a(Division 3 of.the Business and BLDG. ELE C
r D z Professions Coe d my license is in full fur e a e t
• z 0 D Licen I.Lsss,�s Lic.Numb r
' 0 z O Data p .p1♦� Contractor
a x - BUILDING PERMIT
¢ w u OWNER-BUILDER DECLARATION -
X ;LL N "I hereby affirm that-1 am exempt from the Contractors License MISC.-- REFER TO ORD INFORMATION
Law for the fallowing reason.(Sec.703 L5,Business and ProfessionsPERMIT'ISSUANCE - •10.00 VALUATION $/FT.
� - -' Code:Any city or county which requires a permit to construct,alter,
rt ee<p improve,demolish,or repair any structure,prior to,its issuance,also ELEC.CONTR, LIC.NO. ELEC.
i is O S, requires the applicant for such permit to file a signed statement that - TOTAL PE MIT T
X he is licensed pursuant to the provisions of the Contractor's License
i
Law(Chapter 9fcommencingwlth Section 7000)of Division 3 of the
z a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE I'
¢ D STORIES TYPE CONSTR. .
¢ r the basis for the alleged s Codetion.Any violation of therefrom
703 and
� _
n ;$ by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500)):
❑ 1,as owner of the property or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
UNITS-
their sole compensation,will do the work„and the structure is not - DCC.GROUP RES.UNtrs
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '.
Cade: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 $0,FT.FLOOR AREA TOTAL ACREAGE
himself or lhrnugh his own employees,provided that such improve- GAS
or SYSTEM-1 INC.4 OUTLETS 6.00
•r mems are not intended or offered for sale.If,however,the budding I.
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
- prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RS , IND DON PB Other
❑ 1,as owner of the property,am exclusively contracting with ❑ -❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 1JASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,mm who LAWN SPRINKLERS-OVER 5'(EA.) 1.00
contracts for such projects with a contractor(s)licensed Pursuant t0 SEWER-SANITARY-STORM EA.200ft/10.00 '
the Contractor's License Law, TRACT NO: PARCEL NO.
❑ I am exempt under Sec. L ,B.&P.C.forthisWATER HEATER W/VENT -6.00 -
mason
Owner - Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.CJA!/F, .RV
Policy No.�/P3(9'/]Company((�- I. -
❑ CertiO dcuPY's here by I rnisticJ. FIRE SPRINK ENERGY 24
Z Z App
Cc,,fie 'o File H 'nspection division. MISC.- REFER TO ORD.
O AP-pllcant Y❑ N❑ Y ❑ N❑
♦- -
a PERMIT ISSUANCE , 10.00
CC - CERTIFICATE XEMPTIONF ORKF-RS' FLOOD ZONE A.L.U.C.
LU > COMPE SATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars C$100)or less.) -
U O 1 certify that in the performance of the work for which this Per. CITY MECHANICAL PERMIT. FEE FEE SUMMARY
LL F 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.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IOIXOQF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 . SEISMIC FEE
Thereby 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,Cie.C.). ' HEATING UNIT(TO 100,000 B.T.U.) 8.00 -Leader's Name - HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l have read this application and state 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-COMP(3 H.P.of 100,000 B.T.U.) _6.00
hereby authorirc representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH.' MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which CONST.TAX
may in any way accrue against said City in consequen a of the PERMIT ISSUANCE 10.00 /
gm( rtn it. /1 MECH.CONT. - LIC.NO. MECH. QC�
Qf 1 TOTAL 1�-xM TA �U1
i are of ApplicantContracto e ( /�o/lJs✓ h
OFFICE COPY