11755 (4) dT TO FILL IN INFORMATION WITHIN RED LINES -' USE BALL POINT PEN ONLY
1 NG PROJECT IDENTIFICATION PERMIT NUMBER
G APPLICATION & PERMIT
1/ 11�0 Ess TN n^r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11755
Se
�/ OWNERS / 1(-7.J PLAN CHECK VALIDATION
'C/ ngmE QTY. ELECTRIC PERMIT FEE 73 03
vHorvE J /
flgciDRS
yNAM[ OUTLETS-SWITCHES-RECEP 10.00/1.00
T1 LIC.NO. LIGHTING FIXTURES 10.00/1.00 7-7`�
��
'� ADOREss ( APPLIANCES-RESIDENTIAL 4.00
PHONE 4� PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^
APPLICANT'S
AODREss MOTORS SEE FEE SCH:
SERVICE CHANGE 20.00 / r
w o o LICENSED CONTRACTORS DBCLA RATION P� dlo
a i U I hereby affirm that I am licensed under provisions of Chapter 9 n -IS ANC DATE.
y <a (commencing with Section 7000)of Division 3 of the Business and BL ! t EL T7 ,PLG.; MECH.
r m Professions Cade,,,anJ license is is full force a fee
z o w - License Class Lia Number
9 m H w Date Conlocmr
h - - -
a w a OWNER-BUILDER DECLARA O B, LDIN IP IT
A. i,u H I hereby affirm That 1 am exempt from the Canimcfor's License MISC.- REFER TO ORD INFORMATION
to u o e Law for the following reason.(Sec.7031.5,Business and Professions VALUATION - SIFT.
- ai PERMIT ISSUANCE 10.00
`Oto Code:Any demoorcounty which reyuires a ture,prior to
also
¢ ¢ ¢ p improve,demolish,or repair any structure,prior[o its issuance,also ELEC.CONTR. LIC.NO. ,LEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m" lie is licensed pursuant to the provisions of the C'ontractor's License
HiQ Law(Chapter 9(commencingwlth Section 7000)of Division 3 of the �ti7 ld� //y�ugyy
4 D Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u;m by any applicant for a permit subjects the applicant loa civil penalty gLTER-DRAIN -WATER MA.) 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 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,AR EA,COND. 5.00
Code The Contractor's License Law does not apply to an owner of .-
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedorofferedforsale,ll',however,lire building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA.1 2.00
Is
builder will have the burden of proving(h - . -
at he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I;as owner of the property,out exclusively contracting with INDUSTRIAL WASTE INTER. 30.000 El El D El
licensed
car
(ructprs lu construct the project(See'7044,Business LAWN SPRINKLERS-1 INC$V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'The Contmclor's License Law docs not imply -
In an owner of property who builds or.iniproves thereon,and who LAWN'SPR IN KLERS-OVER 5 (EA.) 1.00
comocis for such projects with a contuctor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
Zhu Contractors License Law. TRACT NO. 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.FILENO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby infirm that I have a certificate of consent to xdfhinsure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lab.C.
Policy No. Company
Z ❑ Certified Copy is hereby furnished, FIRE SPRINK ENERGY T-24
Z 2 ❑ Cenifi inspection division.
Applicant MISC.- REFER TO ORD. Y [] NC] Y❑ N�
CE RTI I9 CATE OF EX EMI'1'I ON PROM WORKERS' PERMIT.ISSUANCE 10.00 FLOOD ZONE A.L.UF.
LU COMIIENSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
�
Z This section need not be completed if the permit is lot one TOTAL v N Y N�
U O hundred dollars(S 100)or Iess.)
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F 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.
Q. Uutc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NO]ICE TO APPLICANT. If,after making this Certificate of lix-
? emption,you should became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this petit shall be decried revoked. AIR HANDLING UNIT ITO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 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 HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building lconstruction,and co and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representativesforinspection
np s of
this purposes.s city to enter upon (he
above-mentioned propertytyBOILER-COMP (Dozer 100,000 BTU)SEE FEE SCH. MECHANICAL
hi
(We) agree to save, indemnify anti keep Iormless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
',tiny in any wf.Y accrue against a 'r consequence of the PERMIT ISSUANCE 10.00
+ granting f permit MECH.CONT. LIC.NO. MECH.
- TOTAL. TOTAL
Signature of Applicant/Contrac r Date
OFFICE COPY