11271 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
T BUILDING PROJECT I DENTI FIC TION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
��0 •� BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 11271
OWNER'S - PLAN CHECK VALIDATION
"GE1 1 Oy �0 OTV. ELECTRIC PERMIT FEE -
fil� iE
CONTRA u OR'S K
NAME (:a$.S. ptµ. I��ypi0 UTLETS-SWITCHES-RECEP 10.00/1.00
Llc.rvo LIGHTING FIXTURES 10.00/1.00
f.ONTBACTDR'sPPLIANCES-RESIDENTIAL 4.00
ADORES S GVV �•
q f rli Cf Ar)
Y ' HONEA?rS6,fqQPANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ASS MOTORS SEE FEE SCH. y I
ADDRESS
SERVICE CHANGE 20.00 '/W/_I •1
woo LICENSED CONTRACTORS DECLARATION
< U I hereby affim that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r
Z w (eonunencing with Section 7000)of Division 3 of fl eBusiness and A ¢u BLO ELECT. - PLG: MECH.
H N i Professions Co ,a d y c rise is in full for if ffife�a'JI��
a i m o Lice I lass Lic.Numbe,7:14 W 17 ❑ ❑ ❑
Dote Contractor
x 2 BUILDING PERMIT
¢ BE BE u OWNER-BUILDER DECLARATION INFORMATION
w ;u H I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD VALUATION
H u.oJ Law forthe following reason. 7031.5,Busuiessund Professions PERMIT ISSUANCE 10.00 S/FT.
m � Code:Any cilyorcmmty whichrequiresupermiltoconslrucl,allaq
¢ ea ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0, requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
a w re he is licensed pursuant m the provisions of the Contractor's License r
FiY'
Law(Chapter 9(commencing with Section 7000)of Division 3 of ilia
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
M r$ the basis for the alleged exemption.An
g p he violationufSection703I.5malty S S TYPE ONSTR,
n; � by any applicant fore hundred
subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than flue hundred dollars f8500)J:
O 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,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 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-11NC.40UTLETS 6,00
incurs are not intended or offered for Sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving th . . .
at he did not build or im- BUILDING USE
prove for purpose of sale.). S INDUSTRIAL WASTE INTER30.00 IND CON PB Omar
IDI,as owner of th .e property,ant exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u contmcloAs)licensed pursuant to
the Contractor'sLicense Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sac.—,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00' ACC.DATE 'ACC,FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to salt-insum, ZONING ENG.SITE N0.
or a cerlifici le of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O C Cerlifictl oPy is ham h rmshcd. RE SPRINK ENERGYT24
Z z ❑Applicant-
pY is fi i lb ys ion division.
O Applicant_ (`� MISC.- REFER TO ORD. v❑ N❑ v ❑ N❑
~ r2 PERMIT ISSUANCE 10,00
— CER'11FICATTi OIi EXIiIii FROM WORKERS' FLOOD ZONE A.L.U.C.
LU ? COMPENSATION INSURANC17 PLG,CONTE. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred doll...IS 100)or less.)
U O 1 certify that in the performance of the work I'or which this per- OTV 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.
t DateApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} In NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097.CIv.C.jnee o1'the work for whish 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.19.50
Leader's Address ELECTRIC
• I certify that I have read this application and state that the shove VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stare 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
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless ilia 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.against said City in cunsequence of the
granting of this Dem' MECH.CONT. LIQ NO. MECH.
L�u�9L TOTAL TOTAL
Signature plicant/Contractor Dille I -
OFFICE COPY