10801 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
BOILDING APPLICATION & PERMIT
ADOBgss 10801
�/ 00O BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S - 'r PLAN CHECK VALIDATION
I
NAME - QTY: - ELECTRIC PERMIT - -FEE '
b `/PHONE '
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
/ / 10.00/1.00
LIG
LIC.NO. HTING FIXTURES,
4DDRACTonre �y �(L A15— ppLIANCES-RESIDENTIAL 4.00
k ADDRESS //J�,.//�' 'T
/- 1/2 C-�Al�.4ov PHONE 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 '
ARcH.OR ENG. - SPECIAL CIRCUIT 5,00 - PERMIT VALIDATION
ADDRESS x
`' ZIP EMP.METER OR POLE INS. 20.00 �J )
APPLICANTS/D:.�c5,9 !/ �l/J �'(, MOTORS - SEE FEE SCH.
ADDRESS
_j SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION
Q v. I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commencing with Section 7000)of Division 3 Of the Business and BLDO. ELECT. PLG. MECH.
r N Professions Code and my license is in full force and effect. ❑ O' ' ❑ ❑
z o m License Class�'_.�,�Lica Number
9 H Date Contrnc,
4 y — s. BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER C ARA ION INFORMATIONS
MISC.— REFER TO ORD
X w 1 hereby affirm that I am exempt from the Contractor's License
H oc o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Coda:Any city or county which requires a permit to construct,alter,
¢Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License /`
HiQ
Law(Chapter9(commencingwith Section 7000)of Division 3 ofthe "5!/l
g 4 D Business and Professions Code)or that he is exempt therefrom andOTV. PLUMBING PERMIT FEE
¢ H $ 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 -WATER IEA.) 5.00
of not more than five hundred dollars(8500).)'. -
❑ I,as owner of the property,or my employees with wages as
BACK FLOW PROTECT:DEVICE 4.00 OCC.GROUP PES.UNITS
their sole compensation,will do the work,and the structure is mf
Intended or offered for sale (Sec. 7044, Business and Professions' DRAINS-FLOOR,ROOF,AREA,COND. 5.00
f" Code:The Contractor's License Law does not apply to an owner of
property who builds or improve@.thereon,and who does such work FIXTURES-PER TRAP S.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2,00
builder will have the burden of proving that he did not build or im- - BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Otter
❑ 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 or property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 I
contracts for such projects with mntmctor(s)]I.msed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am 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 a certificate of consent to sal&insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lah.CJ.. -
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z CeHifled copy led wi [he ly inspection division
O Apphcam j MISC.- 'REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ rn - PERMIT ISSUANCE 10.00 FLooD zoNE A.L.u.c.
K CERTIFICATE OF EXEMPTION FROM WOR
LU > COMPENSATION INSURANCE - ' PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ N❑
hundred dollars($100)or less I
V O 1 certify that in the performance of the work for which this per- QTY'.' MECHANICAL'-PEflM1T FEE FEE SUMMARY -
LL F 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.
ii Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 15
} rn NOTICE TO APPLICANT: If,alter 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 be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10P000.EM.) 6.00 -SEISMIC FEE' 4-0
1 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
HEATING UNIT(TO 100,000 B.T.U.) 5.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I C
Lender's Address'
1 certify that 1 have 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 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 IOver 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned pr etl for inspection purposes.
- (We) agre41bili
mnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agjudgments, costs and expenses whichCONST.TAX
may n a y ins and C' in conseyuence of the PERMIT ISSUANCE 10.00gra n thMECH.CONT.- LIC.NO. MECH.i � �(P TOTALTOTAL /�F
9lgnature o Aactor Date -
OFFICE COPY —