10278 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
IWILOING APPLICATION & PERMIT
ADDRESS
U at
O 4C/1
0 I S f-!Y BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10278
OWNER'S
NAME PLAN CHECK VALIDATION
DTV, ELECTRIC PERMIT FEE
M"C4,a�l I- , � PHDNE2S3-/Cp GI
CONTRACTORS
NA
UTLETS-SWITCHES-RECEP 10.00/1.00
i
c LIc.NO. LIGHTING FIXTURES 10.00/1.00
ONTRACTOR'S
ADDRESSPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR PANELS
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. SIGNS TRANS. 3,00
ARC
ADDRESS ENG. SPECIAL CIRCUIT 6,60 P DATION
ZIP rrEMP.METER OR POLE INS. 2000.
APPLICANT'S MOTORS . SEE FEE SCH. PEC 8
ADDRESS
O rl2 5auU FPrNnwl clo ��-. SERVICE CHANGE 20.00
, 02
wo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.60 City,ot.Cupertino
a u I hereby affirm that 1 am licensed under provisions of Chapter 9
r Z w (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
F n ZProfessions Code,and my license is in full force and effect. BLDG. ELECT. PL❑G. MECH.
0 m License Class Lic.Number
o D .-
Date Contractor t
Wo
X i w a OWNER-BUILDER DECLARATION *� �/ ,✓ ` BUI DING PERMIT
a O d U INFORMATION
X 3: LL N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
ar u_w j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT,
f Code:Anycily orcounty which requiresa permit to construct,alter,
IRDS
to Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.GONER. LIC.NO. ELEC.
a oO a requires the applicant for such permit to file a signed statement that TOTAL
W m Ile Is licensed pursuant to IIIc provisions of the'Contractors License PERMIT TO
rZQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
f 4 o Business and Professions Cade)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
M H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE'CONS
by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars($500).): '
❑ 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(S the work,and the structure is not
Code:T or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does an apply loan owner of
Property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.66 SQ FT.FLOOR AREA TOTAL ACREAGE
himself re through his awn employees,Provided that such improve-
Goals or improvement
notment is
old w offethin onefor
year
lL however,tion the,buildingo dbg GAS-EA.SYSTEM-1 1NC.4OUTLETS 6.00
or improvement is sob within one year of completion,the owner.
molder will have the burden of proving that he did not build or im- GAS-EA:SVST - VER 4 (EA.) 2.00 BUILDING USE
for purpose ofsalcJ' INDUSTRIAL W4W INTER. 30.00 ES o CON Re Omer
I,as owner of the property,am exclusively contracting with
I
n d contractors to construct the project(Sec.7044,Business LAWN SPRIN L $` I V 6.00 SSESSORS PARCEL NO.
El 0 El
a Professions Code:The Contractor's License Law does not apply
I an owner of property who builds or improves Ihereon,and who LAWN SPRI S-O .) 1.00
contracts for such projects with a contractors)licensed pursuant to ,
the Contractor's License Law. e7C �f SEWER-SA I R O OOft/10.00 TRACT NO. PARCEL NO.
rcu❑ I ant exempt under Sec. ,B.&P,c for this W ER E ER W 0
Ownet= w. Tn
f Date ( WA STEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION W VR G UI 5.00
1 hereby affirm that I have a certificate of consent fo self-insure,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.l.
Policy No. Company
0 ❑ Certified copy is hereby furnished. J FIRE SPRINK ENERGY T-24
ZZ 11 Certified copy is filed with tile city inspection division.
♦: O Applicant MISC.- RE TOORD. YI] N� Y N�
CC CERTIFICATE 017EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
LUCOPLG
Q. > IT his section need o.I het completed Rif tt Cl permit is for one PLG.CONTR. LIC.NO. TOTAL Y❑ N Y[:] NE]
Q. O
:3 Z h u n dred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compere tion Laws of California.
a Dat` Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificme 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
C.1 such provisions or this permit shall he deemed(evoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.P,M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction leading 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
Leaders Name
Lenders Address HEATI NO UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
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 gO1LER-COMP(3 H.P.of 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 consequence of the PERMIT ISSUANCE 10.00
granfingof this permit. e� , r MECH.CONT. LIC.N0. MECH.
S � / 7o S TOTAL TOTAL
Signet um of Ap lican t/Com racror Uete
OFFICE COPY