14268 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATION / PERMIT NUMBER
APPLICATION & PERMIT .
R°'�°'" 14268
GREs x.� O SANTA-L.uu� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O NER'S
ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
mss' M QTY. ,
rZI�LT_! �M&/ PHONE `�/
' NOILLFALT°R _� `-�-�.. OUTLETS-SWITCHES-RECEP 10.00/1.00 ,3 "
of .nuc.rvo. LIGHTING FIXTURES 10.00/1.00 0
c0NTRACTOR�S� �+ =7 r PP LI ANC ES-RESI DENT IAL 4.00
DRESS •• _
•4- (- f-_ - LE -`.. PANELS IO.00 d '�'PANELS (OVER 200 AMP) 20.00 DATE OF APPLICATION
ARLHI\cLl - J-"'- - PLAN CHECK FEE P.C.NO.
.x'f'
ENGINEERTtrY /U/��s�Ic.No, SIGNS TRANS. 3.00
ARCH.OR ENG. 37'r'- i7 SPECIAL CIRCUIT 5.00 (,d'-- PEsn!TavA LIGATION
ADDRESS 2� 11 pJ
GN Aif-- ZIP Q TEMP.METER OR POLE INS. 20.00 lny_
nook ANTS Q7 MOTORS Ail SEE FEE SCH.
(p �r(r r.r 1�/Cllg-r.0 T/✓D� S10
ERVICE CHANOEv 20.00 7
0 re Hoo LICENSED CONTRACTORS DECLARATION �a1�y p V\-'r 7
< U w I hereby affirm that 1 am licensed under provisions of Chapter 9
G '�,_ �, x IB ANCE GATE
w H (commencing with Section 7000)of Division 3 of 1 Business and su BLDG. ELECT. PLG. MECH.
H N z Professions Cod sd I,y license is in full for d tto 1
z o L - License Class Lia.Number- D J
9 � r� Date�_ Contractor - \ z �
¢ >< F J BUILDING PERMIT
a a ¢ OWNER-BUILDER DECLARATION INFORMATION
o a ° - 'MISC.- REFER TO ORD
F
r. y I hereby affirm that I am exempt from the Contractor's License
U.
Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 !V^'A,Ls.U,�A�TION S/FT.
w J Code:Any city or county which requires permit to construct.alter, 3`1 0 s!"
w> improve,demolish,or repair an structure,prior 10 its Issuance,also ELEC.CONTR. LIC.NO. A
a a ¢ O P P Y P ELEC. 7 ./ /
a o LL requires the applicant to such permit to file a signed statement that TOTAL ERMIT i0
!
w m he is licensed pursuant to the provisions of the Contractor's License '\ /
Hie
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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 end Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
tt Cade:The Contractors License Law does not apply to an owner of
!t:r .r property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 -� S°.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. `
merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 (n
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
,/ builder will have the burden of proving that he did not build or im- RES IND CON PS Other
! prove for purpose of sale.). ' - INDUSTRIAL WASTE INTER. 30.00
1p I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the Project(Sec.7044,Business 0 ILAWN 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 0 LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with' contrac(.0' licensed pursuant to D
the Contractor's License L:w. SEWER-SAN ITARY-STORM V-STORM EA.200ft116.00 TRACT NO, PARCEL NO.
❑ lame tun r •c. .B.&P.C.for this ' WATER HEATER WIVENT 6.00
reason
�i Owner Date WATER SYSTEMpy 5.00 ACC.DATE ACC.FILE NO.
WORKERS'CO PEN ATION DECLARATION WATER TREATRIG EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure, - q
or a certificate of Workers'Compensation Insurance,or a certified �:�'. �? ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). " rip. \\\
Policy No. - Company
O ❑ Certified copy is hereby furnished bt Vx st FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Bled with the city inspection division. u-,
MISC.- REFER TO ORD..
O Applicant Y❑ N❑ Y ❑ NE]
`.
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 /'O ' FLOOD ZONE A.L.U.D.
LL -/ COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG, �- "'
CL Q ('/Iris section need not be completed if the permit 1s for one TOTAL _1� v❑ N❑ Y❑ N❑
- 0 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work f which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
F mit is issued,I shall not employ a pe son in a fanner so as to
U.
U becohe Warkcrs'C California.
Go Date l� Applicam_ ALTER OR ADD TO MECH. 5.00 BUILDING
Gz A v
} m NOTICE TO APPLICANT: If,after making this C rtificate of Ex-
F.. ? emplion,you should become subject to the Workers'Compensation APPLIANCE hxy\Fg' 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
such provisions or this perm t shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 16MC.E_M.) 6.00 c
SEISMICFEE yr a '7%^
I hereby affirm that there is a construction lending agency for EXHAUST HOOD:(WITH DUQT)S v 5.00
the performance of the work for which(his permit is issued(Sec. ;MICROFILM
1 HEATING UNIT IT 100,000'B.T.U.1 8.00 -
3097,Civ.CJ. Q _
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 EL'ECTFiIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 +e
information is correct. I agree to comply with all city and county FLUMBING V 7
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 BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
s� above mentioned property for inspection purposes.
" (We):agree to save, indene nify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against fall ies, I0 merits, costs and expenses which PERMIT ISSUANCE 10.06TU CONST.TAX
Is
it))any way ace ag I sI said City in consequence-of the
grant go hisp mj. MECH.CONT. LIC.NO. MECH'. (�
TOTAL as TOTAL
Sig Marc of Ap ican I ntn clot Date
OFFICE COPY
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