11576 (2) APPLICANT TO FILL IN INFO ION WITHIN RED LINES - USE BAPOINT PEN ONLY
BU LDI NG PROJECT I DENTIFICif PERMIT NUMBER
BUILDING - APPLICATION & PERMIT
j11576
ADUREss
}ay f- Ca--, e /EA/� G�J BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NAMEPHONE��� �W'9f�k 7H PLAN CHECK VALIDATION
C aa�� xDTV. ELECTRIC PERMIT FEE I
AMEf(l.'-{nI�• 1/ Y, PHONE
DONTRACTORs
C
CONTRACTOR
UTLETS-SWITCHES-RECEP 10.00/1.00
P.�saflc,, .; J. ' "k0/( LlcNo %f �� LIGHTING FIXTURES 10.00/1.00
f,OA.nrRAcroR's PPLIANCES-RESIDENTIAL 4.00
f( 1uip y •ret 115_/ PHON4og m'IfM PANELS 10.00 EXlsrDATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.No.
OR
ENGINE 50
LIC,No d 717SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
Z-7,50 GUIs /A / z I P EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION r �� ,�//�
a v sHj I hereby affirm that I am licensed under provisions of Chapter 9 ! ' µ� AryCE D(TE
y a N (commencing with Section 7000)of Division 3 of the Business and - BLDG. E ECT! PLG. MECH.
H w z Professions Code, d license is in full fay'�.pyjy(f• r��"
z o In - License Class Lic.Number✓L-V/-!6- t� t r.^ 1 o'jr"' ❑
Q wrw Date 1' Conlrachn-PYSYNOfN_ i ^�3^�/ �iI"AD�-
¢ y UILDI G PERMIT
s J B
-¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION
o a U affirm MISC.- REFER TO ORD
w; I hereby arm that I am exempt from the Contractor's License VALUATIO
LL N
HLL0 J Law for the following reason.(Sec.703 1.5,Businessend Professions PERMIT ISSUANCE 10.00 to
Code:Any city or county which requires permit to construct,alter,
cee,< G improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. nyq
la -O¢ requires(be applicant for such permit to file a signed statement Ebel TOTAL G A`� PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
F zr Law(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and OT.Y. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
- of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 ---RES 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 F IXTUR ES-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-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, . .1 2.00 BUILDING the owner- GAS•EASYSTEM-OVER 4 IEAsE
builder will have the burden of proving that he did not build or im- RES IND CON 4 PB prier
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,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-OVER 5 (EA.) 1.00
the Cont for such projects with a contrador(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
Ilhc Contractor's License Law.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACO.FILE NO.
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof( .3 ll.Lob.C.I
Policy No. mpany Oad VF-e �NS,
0 ❑ Certified copy is hereby furnished. FIRE SPR INK ENERGY T-24
Z ❑ CertifiWe�d wp is fh�•..��II vuIh the city inspection division.
Applicant K04A/W// f-G. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
rn
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU -
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. '
C O (This section need not be completed if the permit is for one TOTAL Y❑ IN Y ❑ N❑
Z) Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z empRon,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 be deemed revoked AIR HANDLING UNIT(TO 10=C F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I HEA%JNG UNIT(TO 100,000 B.T.U.) 8.00 ����jj
Lender's Nam
Lender's Address e HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC p� QC=-
1 certify that I have read([its application and state that the aboveVENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOER-COMPH.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOIILLER- (3
COMP ,Over 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentionedproperty for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmen costs and expenses which CONST.TAX
may in any wa true against City in consequence of the PERMIT ISSUANCE 10.00
griping of th It. MECH.CONT. LIC.NO. MECH. 1
v TOTAL TOTAL
Si Date
OFFICE COPY