10790 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BULININGILDING APPLICATION & PERMIT 10790
- a �) r
ZZW D O S TAI, Q BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
ME TY. ELECTRIC PERMIT FEE
a, 1410�7z PHONE x'33 86
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
S1,11 TFA" rF LIC.NO. ffs) LIGHTING FIXTURES 10.00/1.00
CONTRACTOR 5 APPLIANCES-RESIDENTIAL 4.00
ADORE s -
/ /.�)w tsa(y PHONE !�I PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 '
AARCH,OR DORESS ENG. SPECIAL CIRCUIT. 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 tLO w'
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION ' 3 " '
<U v I hereby affirm that I am licensed under provisions of Chapter 9 ANCE DATE
y<w (commencing with Section 7000)of Division 3 of the Business and BL G. T. PLG. MECH.
r N w Professions Cod it y license is in full f'up,$nitsffd
z O,n- License C as Lie.Number 77�a�� ❑ ❑
o=H ate Contractor
a Y s
BUILDING PERMIT
¢ S,w OWNER-BUILDER DECLARATION INFORMATION
w ;u y 1 hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD A
F u O¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city.,county whichmilmes apermit to construct,alter,
re 2 Q o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
y w m a, requites the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's LicenseF,/Z
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the mpg,/�
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /
¢II- the basis for the alleged exemption,An
ge p he violation of Section 703L$ STORIES TYPE CONSTR.
n ;_ by any applicant fore permit subjects the ton Civil penalty ALTER-DRAIN -WATER (EA.) 5.00
.(not more than five hundred dollars(5500).):
❑ 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,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 So.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- - BUILDING USE
prove for purpose orsaleJ. INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Ome,
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License
Luw 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 eontractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's'License Law. TRACT NO, PARCEL NO.
❑ tum exempt under Sec. ,B.&POC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
^ or a certificate of Workers'Compense gy Jw�}yanec,or a ceHifie
�s copy tfb,Vry4�����rr((�� .l('Yf�
Policy Nd!w' a n
O ❑ Certifie op here nishe FIRE SPRINK ENERGY T-24
Z
� ❑ Cert if Ci it 'o d' is n.
Applica MISC.- REFER TO ORD. Y❑ N❑ Y❑ N❑
H rn PERMIT ISSUANCE 10.00
CC - CERTIFICATE OF 17XEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or less.)
UO
I certify that in the performance of the work for which this per, FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to DTV. MECHANICAL PERMIT FEE
O W become subject to the Workers'Compensalion Laws of California.
IS. Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 34
G
} US NOTICE:TO APPLICANT: If,after making this Certificate of Rx-
? emption,you should become subject to the Worken''Compensnttou 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=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE .Sa
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097 .0performance)neof the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree I.comply with all city and county PLUMBING
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 BOILER-COMP (Over 100,000 BTU)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 expenses which ERMIT ISSUANCE 10.00 CONST.TAX
may in any w uCc a it Is nee of t
granting fW H.CONT. LIC.N0. TMECH
OTAL
TOTAL
igneture of pplicant/ tetra or Date
OFFICIECOPY