10015 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATI ON PERMIT NUMBER
BIIILOING APPLICATION & PERMIT
a 10015
oREss
7/UYLGi _ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
7
NAMEOWNE
/� 2�j PLAN CHECK VALIDATION
NAME 7fCJ^'t7 ' OTV• ELECTRIC PERMIT FEE
ONE
co HAD TOP's -
NAME UTLETS- ITCHE -RECEP 10.00/1.00
P?SAVxJt1 {rt G LIO.NO. v LIGHTING FI RES 10.00/1.00
ADDRESS Ton's PPLIANCES-RESIDENTIAL 4.00
1171 p4�.A1NJ`1 Lt�0NE 0 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. JSINS TRANS. 3.00 '
ADDRESS eNo. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER ORP LE INS, 0 VAS
APPLICANT'S
AODREas MOTORS EE SCH.
SERVICE CHANGE
O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 I �y
¢ vQy Q v
BO ISSUANCE GATE affirm that I am licensed under rovisions of ha ter
2 wH
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code,and my license is in full force and effect I ❑ ❑ ❑
2 0,� - License Class C 1ALic.Number_�J V
w H B Date-/f g_- -irC Contractor'
¢ s w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
' O ° • MISC.- REFER TOO D INFORMATION
X
;°'w I hereby affirm that I am exempt from the Contractor' recuse,
to Law for the following reason. 703 1. Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
w0 Code:Any city orcounty which requires a permit to construct,alter,
SEQ ¢ Impm",demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEG �f
u °¢ requires the applicant for such permit to file a signed statement that TOTAL EJ/�
F
m u. he is licensed pursuant to the provisions of the Contractor's License P RMIT TO
H 2 ) Law(Chapter 9(commencing with Section 7000)of Division 3 Gfthe
7 4 o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢s-m the basis for the alleged exemption.Any violation of Section 703 L5 ST IES TYPE CONSTR.
n 3 .- by any applicant fora permit subjects the applicant top civil penalty
of not more than five hundred dollars(8500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided Hort such improve.
merits 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 EASYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND 11 0 ON PB Other
❑ 1,as owner.1 the pro INDUSTRIAL WASTE INTER. 30.00
perry,he exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 aSSEssoPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u contmebmis)licensed pursuant In SEWER-SANITARY-STORM EA.200ft/10,00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKF-RS'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,
3800,Lab.C,1.
a No. Company ;
0 is hereby furnished. FIRE SPRINK ENERGY TQ4
Z Z ❑ rtified co is OI•d with the cit spemion division. MISC.- REFER TO ORD.
F p ApplI'mt V N V N�
cc �+ PERMIT ISSUANCE 10.00
- .IiRT 'KATE OP BXIiMPTJO ROM WORKFiHS' FLOOD ZONE A.L.U.C.
UJ COMPENSATI 771 URANCI; PLG.CONTR. LIC.NO. PLG.
M. O ('Phis section need not be c ted if the permit is for one TOTAL Y C] N� Y N�
Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
U. I- 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.
y Date ApplicantBUILDING
>_ W NOTICE TO APPLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F ? Snip'ion,you should become subject to the Workeri 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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLINGUNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby 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,Civ.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 cerlily that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMPLUMBING
ordinances and state laws relating to building construction, and (3 H.P.H,POf 100,000 B.T.U.) 6.00
hereby authorize representatives this city to enter upon the
above-mentioned property for inspection purposes. BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
es
(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 in5qnsequence of the PERMIT ISSUANCE 10.00
granting of this' 'f MECH,CONT. LIC.NO. TOTAL
'S TOTAL (20
Signatur icant/ nt actor Date/. 2
OFFICE COPY