14616 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
•^ PERMIT NUMBER
BW
IL DING BUILDING PROJECT IDENTIFICATION .APPLICATION & PERMIT
1461 {^�
ADDRESS (Q A/�.� Tn n��fUP AW BUILDING- ELECTRICAL-PLUMBING-MECHANICAL {J
OWNER'S I L--"'���.f PLAN CHECK VA ATION
\C NAME r���[' TV, ELECTRIC PERMIT FEE / /y
PNONE ��/J l/ %e0
CONTRACTORS
NA _9392M
UTLETS-SWITCHES-RECEP 10.00/1.00 _
• /-sL"_'S rI', uc.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS I PP,LIANCES-RESIDENTIAL 4.00
r3tvF-1�,avSrPNONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT ('� PLAN CHECK FEEP.C.NO.
OR' uC - I PANELS (OVER 200 AMP) 20.00 -.
ENGINEER
�!� SLIL.NO. IGNS TRANS. �� 3.00 ,
ADDRESS EN O I r V�/ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
�j
AnP MOTORS SEE FEE SCH.EMP.METER OR POLE INS. 20.00
ADDRESS
L1
OREss 5A„AA
SERVICE CHANGE 20.00
E 0 2 LICENSED CON TRACTORS DECLARATION C1tY 1)1 ✓ 1.( /�(�
I_ I hereby affirm that I am licensed under provisions of Chapter 9 ISS A/NCE GATE
vv, a (commencing with Section 7000)of Division 3 of the Business and
¢ LL BLDG. ELECT. PLG. MECH.
r y i Professions o Amy license is in fill]Number for ❑ ❑ ❑
z o m - LiceI Lic.NumM1er
o Dlde Conl radar_ -
a y f BUILDING PERMIT
¢ ¢ a - OWNER-BUILDER DECK
0 a v -INFORMATION
X ;u H I hereby affirm that 1 um exempt from the Contractor's License MISC.- REFER TO ORO
LL o'� Law for the following reason.ISce.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 �. /�A u TI N $/FT.
m -' Code:Any city or county which requiresa permit to construct,alter, Q '
ac ¢ ¢2 improve,demolish,or repair any structure,prior In Its Issuance,also ELEC.CONTR. LIC.NO. ELEC. ��))
c u requires the applicant for such permit to file a signed statement that TOTAL oC.O PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 orthe
f z D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
a H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i by any applicant fora permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (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
their sole 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,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
propertywho builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD,FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve
counts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00'
builder will have the burden of proving that he did not build or I'll. BUILDING USE
RES IND CON PB Other
prove for purpose of safe.). INDUSTRIAL WASTE INTER. 3000.
❑ I,ass owner th
of the property,am exclusively contracting with ❑
licensed contractors : 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 s th does not apply
to tr owner of properly who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such cene L wIOI a contrudmfA licensed Puusuunt v, SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT N0. PARCEL NO, i
❑ I am exempt under Sec..,]I&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 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 theop Sec 8 ,Lab. U. Q� y
Policy NOG( o,L a. L-.-
❑ Certil'ie Copy is here furnished.
N FIRESPRINK ENERGY T-24
Z Z the city inspection division. MISC. REFER TO ORD.
0 APP iCaOI y� No y � NE]
CC W C IFIL l OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section peed not be completed if the Permit is for one TOTAL Y N❑ V N�
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this Per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil 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. p
u Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /.j
} W NOTICE TO APPLICANT: If,after making this Certifeale of Ex.
Z emption,you should become subject to the Workers'Compensation - APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply Willi FEE
U such provisionsor this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �O
I hereby affirm that there is u construction lending agency Rx EXHAUST HOOD WITH DUCT) 5.00 CmL
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's NAddress HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC io
I certify that I 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 In building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby,authorize representatives Of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
May 'n Lie against said City in consclence of the
g f this permit. MECH.CONT, LIC.NO. MECH.
�� TOTAL TOTAL
SfWdrd O ic' Contractor Dat
OFFICE COPY