9154 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.'USE BALL POINT PEN'ONLY
BUILDING PROJECT IDENTIFICATION - PERMITNUMBER
SoILDIN/GJ/ / t . ` = 1/ � 1� APPLICATION & PERMIT
A0196 I W W O WF `-•�1
O0 BUILDING -ELECTR L-PLUM ING-MECHANICAL 9154
OWNER'S
NAME n PLAN CHECK VALIDATION
W 10 lavvk Pa l yYte/- PHONE'136 42' 5 D . �,!€LF,CTR ERMIT FEE
CONTRACTORS
NAME Iny� � � , OUTLETS SWITCHES-RECEP 1 1.00
mr `.�l.U. A 41C,Np, 41-7 6 LIGHTING FIXTURES 1 /1.00
CONTRACTOR'S -
ADDRESS /; APPLIANCES-RESIDENTIAL 4,00
11� Plaza. 50 LLA,• PHONE 44q I01$ PANELS 10.00
DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00
pq � PLAN CHECK FEE P.C.N0.
ENGINEER
uc.rvp. SIGNS TRANS. ' 3.00
ADDR.SS PERMIT VALIDATION
ADDRESS � SPECIAL CIRCUIT •� 5.00
zIP ` EMP.METER OR POLE INS. 20.00 PAID
ADDRESSTS MOTORS SEE FEE SCH.
'• . SERVICE CHANGE 20.00 JUN 2 p 1585
°02
r o° LICENSED CONTRACTORS TEMP.POLE 30.00 -
Q i I hereby affirm that I am licensed under provisions of Chapter 9 l 1n0
w a (commencing with Section 7000)of Division 3 of the Business and
H ° Professions Code,and my license is in full for"and effect. , BLDG. EG PLG. MECH.
'z o License Class Lic.Number
O z I- ° Date Contractor �� ❑ ❑ ❑
she J - - ` BUI I G PERMIT
s 0 w OWNER-BUILDER DECLARATION 1 FORMATION
X ;` w I hereby affirm that I am exempt from the Contractor's License MISC.- R ER TO OR
u o¢ Law for the following reason(Sec.7031.5,Business and Professions - 1 VAL TION $/FT.
r - PERMIT ISSUANCE
ge w j E Code:Any city or county which requires
permit[D construct,alter, _
K rt 4 O improve,dome""
Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. /
EC. //
y w m u- req air'c the d Puts for
such Penn
it to f'h signed stalem¢pt that TOTAL ERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
HiQ Law(Chapter9(commenci ng with Sect ion 'he Cup
o(Division3 of the
Business and Professions Code)or that he is exempt therefrom and. DTV. PLUMBING PERMIT FEE
M H the 68515 for[Ile alleged exemption:Any violation of Section 7031.$ STORIES TYPE CONSTR.
n3 by any applicant for a permit subjects the applicant[oacivilpenatry ALTER-DRAIN -WATER (EA.) 5.00
of not more than five h
u
ndred dollars($500)J:
❑ I„as owner of the=propetly,bI my employees with wages as BACK FLOW PROTECT.DEVICE 4,00
Iheirsole 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,AR EA,CON D. 5.00 -
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 '
himself or through his own employees,provided that such Improve-
SQ FT.FLOOR AREATOTAL ACREAGE
ments are not intended or offered for sale.If,however,the building GAS=EA'.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one'year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4(EA.) 2,00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON Pe Omer
.
❑ 1,as owner of the property,am exclusively contracting with 1:1 El 11 1:1 El
contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS 1 INC 5 6.00 ASSESSORS PARCEL NO,
and Professions Code:The Contractor's License Law does not apply - V.B.
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
the Contractor's License Law, SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date, WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure; -
or a certificate ofZONING;Workers'Compensation Insurance,or a certified ENG.SITE NO.
cop thereof(Sec.3800,Lab.CJ. -
o y No. Company
Dified c py Is hereby famished. FIRE SPRINK ENERGY T-24
Z Z ❑ I �op it Bled wit the g'mspection'division. - - y ❑ N❑ Y ❑ N❑'
� O Applica f(Qiyt�.�. MISC.= REFER TO ORD.
LU ; CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR.- LIC.NO. PLG.
D: O (This section need not be completed ifthepermit is for one TOTAL Y❑ N❑ Y E] NE]Z hundred dollars(S 100)m less.)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
0 y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING "
>_ US NOTICE TO APPLICANT: If,after making this Certificate of Ex-
FZ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK.
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IOAOOC.F.M.).. 4.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby afformthal 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,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) ' 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) - 4.00 -
information correct I vret to comply with all city and county BOILER-OOMP(3'H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate lawss relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. 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 ity,in consequence of-th¢ PERMIT ISSUANCE - 10.00 -
gmntl f this permit
M CH.CONT. LIC.NO. MECH.
6 � TOTAL TOTAL 1
v Signature 01 ApplicantjCon tract or Date -
/ OFFICE COPY