10875 (2) APPLICANT TO FILL IN I RMATION WITHIN RED LINES- L�BALL POINT PEN ONLY
L . PERMIT NUMBER
BUILDING PROJECT ]DENTI ATION
BUILDING - - APPLICATION & PERMIT
ADDRESS 8 . Q �art�. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 10875
OWNER'S ' PLAN CHECK VALIDATION
N" 7ME
1 C yip 1 (` OTY. ELECTRIC PERM IT FEE -
r NN f. `W J - PHONE
GONTRAcroRs
NAUTLETS-SWITCHES-RECEP 10.00/1.00
"� r' n
{,QY'f:. V LIE A&IJ 7d LIGHTING'FIXTURES 10:00/1.00
CONTRAS
APPLIANCES S-RESIDENTIAL 4.00
,1 L'
2 UC I bdPHONE2_i5.g4 � PANELS10.00 _ DATE OF APPLICATION
RCR(TscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER ,
- LIC.NO. SIGNS TRANS. 3.00 '
ADDRESS ENG. ' SPECIAL CIRCUIT 5.00 - _fAi*y,QuonnON
^11YY
'ZIP EMP.METER OR POLE INS. 20.00 EB
APPLICANT'S
ADDRESS OTORS, SEE FEE SCH. ^"
- 1yBE
SERVICE CHANGE 20.00 ,,
w ¢ i 'C'fl Of C
F n o LICENSED CON'T'RACTORS DECLARATION Vp(1rtInO '
< u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
H z w (commencing with Section 7000)of Division 3 of the Business and
w a a BLDG. ELECT. PLG. M
H m i Professions Cod• and��y license is in full forp�.y�sl,pf
o z m o Licenu las Lia Nwuber�.Y_O�- I;S___ � � ❑
Date �=] Contractor qJ! f.
BUILDING PERMIT'
a
¢ a OWNER-BUILDER DECLARATION¢ w v - - - INFORMATION
w3 LL H 1 hereby affirm that 1 anh exempt from the Contractor's License MISC.- REFER TO ORD
LLoa Law for the followingreasoa.(Sec.7031.5,Businessand Prolessions PERMIT ISSUANCE 10.00 VALUATION -$/FT.
� - Code:Any city or county which requires a permit to construct,aIle',
Qa Q 0 improve,demolish,Of repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n w m¢ requires the applicant for such permit[o file a Signed statement that . , TOTAL PE MIT TO
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 of the .
s o Business and Professions Code)or that he,is exempt limmfmm and OTY. PLUMBING PERMIT -FEE
¢ t- m the basis for the alleged exemption.Any violation of Section,7031.$ STORIES TYPE CONSTR.
n3 .- by any applicant for a permit subjects the applicant Loa civil penalty ALTER-DRAIN`& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:4
❑ 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 Ore structure is not OCC.GROUP RES.UNITS
,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 docs such work FIXTURES-PER TRAP .5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided tlmt'such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
meats are not intended or offered for sale.If,however,the building -
or impruvmnent is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). m
INDUSTRIAL WASTE INTER. 30.00 RES IND CON , PB Oar
❑ I,a5 uwuer of tire m
e properly,am exelu,ively eomcling with ❑ ❑ ❑ ❑
licensed contractors to 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 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 contractor(s)licensed pursuant t0 SEWER-SANITARY-STORM EA.200it/10.00
the Contractors License Law. TRACTNO. PARCEL NO.
❑ I am exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPRNSA'I'ION DECLARATION WATER TREATING'EQUIP. 5.00
I hereby affirm that I have o certificate of convent to'self-insure, - ZONING ENG.SITE.NO.
or u certificate of Workers'Compensation Insurll nqc,or a cert ifieA
copy thereof fSec.3800,Lub.C.l.
Policy No. • C'omPa _�V
0 O Cerlit copy is her furnished. + '
Z Z C d o y is wi h he city io5peetion division. FIRE SPRINK ENERGY T-24
Applican - MISC.- REFER TO ORD. Y ❑ N v ❑ N❑
, PERMIT ISSUANCE 10.00
.LU CIiRT'l l°ICCOMPE I AI ION INS FROM WORKERS'. FLOOD ZONE 'A.L.U.C.
'. W � � � .COMPENSATION INSURANCE PLG.CONTR. uC.NO. PLG.
Q. O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F PMit is issued,I shall not employ any person in any manner so as to
U become subject to.the Workers'Compensation Laws of California.
i- Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE '1'O APPLICANT': If,offer making this Certificate oC .
F ? einption,you should become subject to the Workers'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
CONSTROCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 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 H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I Certify that 1 have read this opplicmimr and state that the above VENTILATION'FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and countyIt
PLUMBING
ordinances and state laws relating to building construction, and BOILER•COMP(3H.P.or 100,0008.T.U.) 6.00
hereby authofioe representatives of this city to enmrrupon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. ' MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of i MISC.,-- Vyy ( REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ma in any wa accrue,againsL'said City in consequence of the PERMIT ISSUANCE .10.00
ngo of to eon. MECH.CONT. LIC.NO. ` MECH.
TOT TOTAL
w nature of ppli ab[/Con(motor Date
OFFICECOPV' '( - -