18903 (2) APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI N(.OPROJECT I DENTI FICATION - PERMIT NUMBER
BUILDING,) APPLICATION.& PERMIT p Q O
ADDRESS 0 J
3 L CIA ST14 - BUILDING-ELECTRICAL-PLUMBING-MECHANICALa,.
OWNER'S
u AME PLAN CHECK VALIDATION
V 136 LZ5Z$I DTV. ELECTRIC PERMIT FEE
'PHONE
enure"croRs UTLETS-SWITCHES•RECEP 10.00/1.00I
Q7
1/. m e-R__, LIC.No LIGHTING FIXTURES 10.00/1.00
ADDRESS rofl's APPLIANCES-RESIDENTIAL - 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ORROHIr I:cr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER - S[
LIC.NO. SIGNS TRANS � 3.00 IS17y
ADDRESS ENG:. SPECIALCI CUIT 5.00 - PERMIT VALIDATION
ZIp EMP.ME R OR,PO tE INS 20.00
APPLICANTS MOTORS EE FEE, SCH. r-r. ^,
ADDRESS `J
SERVICE CHANGE ^A t-00
'09 LICENSCD CONTRACTORS DECLARATION
FU w 1 hereby affrm that I am licensed under provisions of Chapter 9 S� ISSUANCE DATE
a u (commencing with Section 7000)of Division 3 of the Business and y u�. BLDG. ELECT. PLG. MECH.
r n i Professions Code,and my license is in full force and effect. e ❑ ❑ ❑
o i m o License Class Lic.Number
r w H j Date ContractorF/�`
a m E LI ;( �I p BUILDING PERMIT
¢ ¢w a OWNFIR-BUILDIiR DECLARATION
o A v � WINFORMATION
E
0 y 1 hereby affirm that I am exempt from the Contr t s License MISC!, REFER TO ORD
a- o j Law for 0m following reason.(Sec.7031.5,Businessa ofessions $/FT.
I- - I (PERMIT ISSUANC Q� 10.00OD
Code:Any city or county which requiresa perminoco tucLalter, EOf CONTR. 1 .NO.¢ ¢ improve,demolish,or repair any str¢tureprior In its nee,also ELEC.
O LL requires the npplCant Ibr such permit to file a signed s[a pent That / .y j - TOTAL MIT TO
n w m a he is licensed pursuant m the provisions of the Conlr.- 's License` I�tl
rz >
Law(Chapter 9(commencing with Section 7000)of Dwis n3 oft htd+/'1/�
i o Business and Professions Code)or that he is exempt Cher from an DTV. fi�PLUMBING PERMIT FEE
¢f the basis for the alleged exemption.Any violation of Secti n 703 5 � STORIES TYPE CONSTR.
� ;� by any applicant fora hundred
sonars;the applicant toaciv pe ty ALTER- RAIN&VENT-WATER IEA.) 5.00
of,n t More than five hundre subjects the p li
J9 1,as owner of the properly,or my employees will ages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will,do the work,and the s[ ure is not
intended or offered for sale (Sec. 7044, Bainess,�ppPP P,$fiessions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not ap(o does
of
property who builds or improves thereon,and who docs such wort IXTUR ES•PER TRAP 5.00 $0.FT,FLaoR�f EA TOTAL ACREAGE
himself through his own employees,provided that such improve-
menus arere
not intended or offend for sale.If,however,the building � GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the o mer GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build im BUILDING USE
Proveforpurpose ofsale.). - INDUSTRIAL WASTE INTER. 30.00 ' RES IND. CON PB Other
❑ I,as owner of the property,am exclusively contmcli i ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,B si ss LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does n apply
to an owner of properly who builds or improves thereon. ' d who LAWN SPRINKLERS-OVER 5(EA.) 1.00
con tracts for such projects with a contractor(s)licensed pu aunt to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO. ,
O I am exempt under See.-,B.&P,C.for Illi, WATER HEATER W/VENT 6.00
reason If or
Owner Date {. WATER SYSTEM 5.00
PCL.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WSRT ATI L14P. 5.00
1 hereby affirm that I have a certificate of consent to sell insure
or a certificate of Workers'Compensation Insurance,or a certified p 0 ZONING ENG.SITE NO.
copy thereof(Sea 3800,Lab.C.).
Policy Na. -Company
Q ❑ Certilled copy is hereby I'urbishod. O - FIRE SPRINK ENERGY T2
Z Z ❑ Certified copy is filed Milt the city inspection division.
F- O Applicant ISO.- 'REFER TCF-ORD. Y ❑ N❑ Y ❑ N❑
� y CERTIFICATEOF EXEMPTION FROM WORKERS' PER NCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE: PLG.CONTH LIC.NO. pLG.
CL Z (This section need not be completed if the permit is for one - - TOTAL Y❑ N❑ y [:] N❑
hundred dollars IS 100)or less.)
Y O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H mit is issued,I shall not employ any person in any manner so as to
O uu become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 VDNIG
} a NOTICE TO APPLICANT: If,after making this Certificate of lix-
Hv� emption.You should become Subject to the Workers'Compensation APPLIANCE 5.00 provision, of the Labor Code, you must forthwith Comply With Such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER l0,00DC.F.M.) 6.00 1 hereby affirm that there is a constructioti lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) .8.003097;CIv.CJ.Lender's NHEATING UNIT(OVER 100,000 B.T.U.)9.50/Lender's Address 7r . Q
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) - 4.00 -vJ
information is correct. I agree to comply with all city and countyPLUM ING
ordinances and Mate laws relating to building construction, and BOILER-CON?(3 H.P.or 100,000 B.T.U.) 6.0dp-L
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. mp,Q1UlANICAL
above-mentioned property for inspection purposes. E
(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
in any
way_accrue agains said City in consequence of t e PERMIT is OO 10.00 �Q7
r gof thi permit. MECH.CONT. LIC.NO. MECH. -
h
TOTAL .00J TOTAL 3s.
gnature of App(cant ractor Date I -
OFFICE COPY