11047 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAI ' POINT PEN ONLY
BUILDING PROJECT I DENTI FICATIC PERMIT NUMBER
BUILDING APPLICATION & PERMI I
ADDsvl,.ts /46'O 2- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 11047
OwNER'S mal-• '-., a PLAN CHECKVALID A 1ON
CITY.'.. . ' ELECTRIC PERMIT 13 FEE
PHONE 6 a -7 1/,,&
CONTRACTORS
NAMEUTLETS-SWITCHES-RECEP 10.00/1.00 l
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
S3.�tiE> 7fG/' PHON J-7� PANELS 10.00 DATE OF APPLICATION
AARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS E"O' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o D LICENSED CONTRACTORS DECLARATION
a v s"j I hereby affirm that I am licensed under provisions o f Chapter 9 �[L C% rd,n!(, o G L, ISSUANCE DATE
y z iwith Si7000
(commencng ecton )of Division 3 of the Business and¢ ^� BLDG. ELECT. PLG. MECH.
Professions C a y license is in full fore
Z o er'i-� License las Lic.Number ® ®,
Q Z r O ace ., Contractor
P m f t BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
w u INFORMATION
w 3 A r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
�q VALUATION $/FT.
FLL0 < Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
� w0F Code:Any city Orcounly which requires a permit to construct.alter,
i /�bOO
¢ ¢ ¢0 mprove,demolish,or repair any structure,prior tilLICNO
or to Is issuance,also ELEC.CONTR. . . ELEC.
wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
Fii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe .PW/NNiN��OdL
3 4 4 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT - FEE r
¢ r B the basis for the alleged exemption.Any violation of Section 7031.5 �' " r STORIES TYPE CONSTR.
i ; ,. by any applicant let a permit subjects the applicant toa civil penalty ALTER-DRAIN (EA.) 5.00 ^ '
of not more than live hundred dollars($500).): w/ j C'
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.uNrts
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 does 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 that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11 INC.4 OUTLETS 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 im BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER30,00 RES IND CON PB Ore,
.
❑ 1,as owner ol'the property,am exclusively contracting with 13 ❑ ❑ 1:1 Ellicensed contractors to construct the project(Sec. 7044,Business LAWN SPR IN KLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License Law does not apply
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 contracums)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ [amexemplunder Sec. ,B.&P.C.forthis WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sel Ginsum. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereo,C}SS`3 8W,Lab.C.)Q� r' L 6 In
Policy Nq/ S F('(mpany - / �-
0 ❑ Certified ropy is hereby furnished.
Z C� c a Iled with (he city inspection division. FIRE SPR INK ENERGY T7q
��y MISC.- REFER TO ORD. YE] NE] Y ❑ N❑
M T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.0030- FLOOD ZONE AL.UF.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLC.
1 0 (This action need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars($I00)or less.) _
U 0 I certify that in the performance of the work for which this per. CIM -MECHANICAL PERMIT FEE FEE SUMMARY
lL 1- mit is issued, I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California. r
.f
0.WDate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
w W NOTICE TO APPLICANT: If,after making this Certificate:of F.x.
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 FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.FM.) 6.00 SEISMIC FEE D.t
1 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 OU
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to 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 BTUI 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 PERMIT ISSUANCE 10.00 CONST.TAX
in any way accrue against said City in conse once o the
4m-Y
ranting of this permit. MECH.CONT. LIC.N0. MECH.
TOTAL L TOTAL �t� SS
ignature of pplicant/Contractor ate
OFFICE COPY f��Z- y17115#