9433 (2) '...IAPP► C `f TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN,ONLY
BUILD I NG PROJECT I DENTI FICATION PERMITNUMBER
BUILmum APPLICATION & PERMIT
a DREss , 9433
�/ 01 _ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
NAME �OLsC/ eq�/T+ DTV. ELECTRIC PERMIT - FEE
• PRONEStq
a .
rvTRACTORs
NAME
UTLETS-SWITCHES-RECEP 10.00/1.00
FO Ly tN19 ie5 tA E C V C1 LIGHTING FIXTURES 10,00/1.00
CONTRACTOR s
Anne
nN
C55PPLIANCES-RESIDENTIAL 4.00
(0(1 S PHONE - B PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3,00
AAR C" OR DDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00 n
APPLICANT MOTORS SEE FEE SCH. K Ltid�J
ADDRESS
SERVICE CHANGE 20.00 / (/•
w
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
acow 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
�A ¢a BLDG. ELECT. PLG. MECH.
F w i PLrofessions ClCod ndR y license is in(all forfg ilq IT .9 ❑ O ❑
o z m o icense a Lic.NumM1er [.T
Dale Contractor
a x s Ir: BUILDING.PERMIT
a OWNER-BUILDER DECLARATION x b e
5 0 u, u INFORMATION
w ; s
LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fay ¢ Law for the fallowing reason.lSec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city Orcoumly which requires a permit to construct,alter,
QQ ¢ � improve, or repair any structure.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
" wO ¢ requires the applicant for such permit to File a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Conlnmtor's License -
� ii Law(Chapter 9 fermmencingwith Section 7000)Of Division 3 ofthe
si ¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
c
¢ H S the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects the applicant loa6vil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500))'.
❑ I,as owner of the property,or my employees with wagesas 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 and Professions DRAINS-FLOOR,ROOF,AR EA,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 Sa FT.FLOOR AREA TOTAL ACREAGE
• inents are otinthhis ownemployees,for
provided ever,hat ch improve GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
mems are not Intended or offend for side.If,however,the building
or improvement is mid within one year of completion, owner. GAS EASYSTEM OVER 4 IEA.) ' 2.00
builder will have the burden of proving that he Aid notbuild
- . -d or im� - BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with 1:1 1:3
licensed contractors m construct the project(Sec.7144,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 un 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 to SEWER-SANITARY-STORM EA.200ft/10.00
the 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.FILE NO.
WORK ERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a Certified
copy thereof ft" ab,C.).
Policy NAL'p-L3$.
o1
0 ❑ Certified copy shereby furnished. FIRE SPRINK ENERGY T24
Z 2 P Certified copy is filed with the city inspection division.
~ O Applicant MISC.- REFER TO ORD. Y E] N� Y [] NEJ
�+ PERMIT ISSUANCE 10.00
CC - CERTI PICATIi OP EXEMPTION PROM WORKERS' - FLOOD ZONE A.L.UA.
LU COAIPENSWION INSURANCE PLG.CONTR. LIC.NO. PLG.
0' o (This Section need not be completed if the permit is for one TOTAL Y❑ NE] Y E] NC]
::) Z hundred dollars IS 100)or less.) -
0 O I certify that in the Performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO M 5.00 BUILDING
} SO NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- Z emption,you should become subject to the Workers'Compensation APPLIANCE5.00 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 UN O 4.00 -
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNI V •P,MJ 6.00 SEISMIC FEE
I hereby affirm that Olen is a construction lending agency forEXHAUST HOOD T D 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 NameIOU BAN 1�
Lender's Address_. a HEATING UNIT(OVER 100,000B.T.U.19.50 ELECTRIC
I certify that I have read this application and state Iliac the above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city and county PLUMBING
ordinances and state laws totaling to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 +f1
hereby entiorite representatives tarries of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL pl J
above-mentioned properly tarvesp ofth i purposes.
(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
may in any way accrue ainst said City in consequence of the �'�
granI g ftIR per L MECH.CONT. LIC.NO. MECH.
JJ/yy���`'.'A{� r 9-S A: TOTAL TOTAL
Signature of Applicant/ nt to e
OFFICE COPY