11352 (2) APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
RDILDING
°°08�o s.s-c -uNc- 11352
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNEH'S�l PLAN CHECK VALIDATION
NAME vI�`-� �i[�(� �d> OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME4r 68 G#eM_MCV IFIS Llc.No LIGHTING FIXTURES 10.00/1.00
.ONTRACTOR's C ' L �/ ` APPLIANCES-RESIDENTIAL 4.00
AD°RESS'3`43 FV1J0. S` (T/CJ
1 HONE . �� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,06 PLAN CHECK FEE P.G.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AOGRESS END' SPECIAL CIRCUIT 5.00 PER MIT VALIOPTION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SCH. /
ADORE Se
SERVICECHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
TIE
v wI hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
y< u (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
r o i Professions Ca�1 (cense is In full C°r�ce�gd fjygt.
oi=o License Class Q-1 Lic.Number•v7r1-! ❑ ❑ ❑
F w r j Date 45W Contractor
¢ se f -1 BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
¢o d u INFORMATION
E
; LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
H u o� Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Z ,^�f Code:Any city or county which requires a permit to ter,
tett ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i O¢ requires the applicant for such penait to file a signed statement that TOTAL
al $ m he is licensed pursuant to the provisions of the Contractor's License PER IT p
H z a Law(Chapter9(commencing with Section 7000)of Division 3 oflhe
S i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I- the basis for the alleged exemption.Any violation of Section 7031.5 DRIES TYPE CONSTR.
byany applicant fare permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER (EA.15.00
of 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,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 SG.FT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA-..SYSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or hnproverI 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 of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am 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-OV ER 5(EA.) 1,00
contracts for such projects with a comractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have u certificate of consent to sal Ginsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,LAC.).
Policy No. Company
❑ Certifiedcopyishere urnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifie py is fjfedl w' Ole it pe n division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Q Applicant �� V N V N
~ rnPERMIT ISSUANCE 10.00
� - CENTIFICA EOF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.c,
W COMPENSATION NSURANCE PLG.CONTR. LIC.NO. PLG,
Z I (This section need not be completed if the permit is for one TOTAL Y❑ N C] V C] N❑
hundred dollars IS 100)or Irur)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- 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.
G. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
previsions of the Labor Code, you must forthwith comply with FEE
C..) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOCF.M.) 4.00
CONSTRUCTION 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,performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I Imve read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating t0 building construction, and BOILER-COMPI3 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 BTUI 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City inconsequence of the
grand of(h
MECH.CONT. LIC.NO.is pet MECH.
m(j/g�
re/U&
TOTAL TOTAL
Smgn9ture of/sppllcant/Contractor Dole
OFFICE COPY