11915 (2) APPI'ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
DUIWING APPLICATION & PERMIT
ADDRESS
TWW7.4;�,O �.filet�� �,, CLy� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1191
s OWNER'S rn� I .�7 r PLAN CHECK VALIDATION
NAME y�y�--.fes'/`//(,(/ 1 , .].4✓inz'6- CITY. ELECTRIC PERMIT FEE
700 �'w `.eAA-,r P-ONE 7f.0 Q'
DTDR's
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME l'
Iv yE It �i(Aevn7gg64 A& Ic.No, .'�.nl LIGHTING FIXTURES 10.00/1.00
ADORE TOR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
W/YJES /�/��/ orvE Q//R PANELS 10.00 DATE OF APPLICATION
ARCHITECT 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 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH. l'�_w-�•rs-1
ADDDRESSDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION ATE
aF v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCEE DATE
N C n (Commencing with$CCllaa 7000)of Division 3 of the BusinessBLDG. ELECT. PLG MECH.
H O zo Professions C A' I m I r e is in full force al f ❑
zO2 License Clasa on Number
9 m H Datc ContractorII
as m f BUILDING PERMIT
o
T O OWNER-BUILDER DECLARATION INFORMATION
w ;u E, I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
HU0< Law for the following reason.(Sec.703L5,Business Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit toconsruct,alter,
feQ ¢ 0 IInpNVe,demolish,Ur pepmr aty Structure,prior IJ it,esnance,also ELEC.CONTE. LIC.NO. ELEC.
K0,
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
tE w he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 1)(commencing with Section 7000)of Division 3 of the L� G
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT . FEE
rc r $ the basis for the alleged exemption.Any violation of Section 7031.5
STORIES TYPE CONSTR.
by any applleant for a petsu
it bjects the applicant Ica Civil penalty
of not more than five hundred dollars(4500).1: ALTER-DRAIN -WATER (EA.15.00S-'
❑ 1,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,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 r SO.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.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA) 200
builder will have the burden of proving that h - . - . .
e did not build or im, BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER, e®30.00 RES IND CON PB Omar
❑ I,as owner of the property,am exclusively Contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC WAA18. 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-OVER5(E(1.)µ 1100
contracts for such projccte with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORM'_ S240ift/10.00 P\Q TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,L&P.C.for this WATER HEATER W/VENTp6.00
reason nS'G
Owner Dale WATER SYSTEM \V 5.00 ACC.DATE ACC FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that 1 have a certificate of consent in self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
�j copy thereof(Sec.3800,Lah.CJ. /J
Policy No. Company e
O ❑ Certified copy is hereby furnished. I K ENERGY T-24
Z Z .❑ Ccrnifiell ony 'n ❑ win�I the oily inspection division.
OT Applieant MISC.- R FEET ORD. v ❑ N❑ v ❑ N❑
CC ul PERMIT ISSUANCE 10.00 d
- CIiRTIF'ICATIi OP Ii XI: 1P ION I'ItOM WORKERS' FLOOD ZONE A.LU.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.No. PLG,
IL 0 (This section need not he completed if the permit is for one TOTAL a U Y❑ N❑ Y❑ IN
hundred dollars(S 100)or Iess.)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of ISx-
F ? emption,you should became subject to the Workers'Cmmpensatlnn APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this peril shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER I0,000C.EM.) 6.00 SEISMIC FEE
1 hereby affirm Oat then: is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UNIT(OVER 100,000 B.T,U.)9.50
Lender's Address ELECTRIC
ie I certify that I have read[his application and stale than the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and slate 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 BOILER-COMP (Ova1100.000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(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 in consequence of the PERMIT ISSUANCE 10.00
gran' of n is p nit. MECH.CONT. LIC.NO. MECH.
Id TOTAL TOTAL
Si naRlrC of
g pplic onl c[ar Dale
OFFICE COPY