11735 (2) APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESS !
,' 77 DM at � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL , 1 1 1 735
OWNER'S PLAN CHECK VALIDATION
• - _ QTY. ELECTRIC PERMIT - FEE .
J10NE
CONTRACTOR, OUTLETS:SWITCHES-RECEP 10.00/1.00
.NO. LIGHTING FIXTURES . 10.00/1.00
Dns
ADDRESS - PPLIANCES-RESIDENTIAL ' " 4.00
ADDRESS q
Oa "SIP"Ce4ANE�p� PANELS 10.00 DATE OF APPLICATION
RDNrtacT - PANELS (OVER 200 AMP) •20,00 - PLAN CHECK FEE P.C.No.
O
OR '
ENGINEERu - -
LIC.N- SIGNS TRANS. - 3.00'
ARCH.ORENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 aU
APPLICANTS
ADCRESS ,MOTORS - - SEE FEE SCH.
SERVICE CHANGE 20.00 '
o o LICENSED CONTRACTORS DECLARATIONPAIL
a v 1 hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE GATE
Hry (commencing with-Section 7000)of Division 3 of the Business and _ - �.+ BLDG. ELECT. PLG, MECH.
r N' Professions CoMand my license is in full f e nhsfF I!' ❑ ❑ ❑
Limnse lass Lic.Numtie 7�^e � 4 - - 1
wF Date - ,Contractor '
¢ Mof CuI erhnu. BUILDING PERMIT
a ¢ OWNER-BUILDER DECLARATION INFORMATION
aoa�' REFER TO ORD
w S u y I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION $/FT.
FLLo ¢ Law for the following reason.(Sec.703 t.5,Business and Professions PERMIT ISSUANCE. 10.00 4
Code:Any city or county which requiresa permit toconstrue a ter,
rcrcao 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 136--f PERMIT TO
e- w m he is licensed pursuant to the provisions of the Contractor's License ^
z aLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe �LrH/T EG 6C-71
D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT n FEE
¢ r the basis for thealleged exemption.Any violationof5ection7031.5 STORIES TYPE CONSTR.
i,; $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of
not more than five hundred dollars($500).): ,
❑ .1,as owner of lire 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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
.•I
himselforthrough ownemployees,for Sale.Ii,ed however,the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems are nut ugh his
or emplo ee sale,If,however,the mpWing
or improvement.is sold within one year of completion, the owner- GAS'EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES, IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ,
❑ I,as owner of the property,am exclusively U ntmeting 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:'I he 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 a conlnmtorfs)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA:200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec,-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner .Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORURS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 I.- Bffirm that I hove y,yM .,to of consent to nett-insure, - - -
or a ecrtilicme of Work• '�WgxSul ion Insurance,or u certified ZONING ENG.SITE N0.
co Py Ih ere o(1 Se c,3 gbh, b.C.).• T +
Polley NoJ;�_1' 1pa •1
O ❑ Certified co Is he yfnrni+ ed FIRE SPRINK ENERGY T 24
Z Z 13CcRifi opy le in c ection division. MISC. REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
to :RT13a 17 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLODDZONE A.L.U.C. -
L �_ _ COMPHNSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
CL C3 (This section need not be completed if the Permit is for one TOTAL Y❑ N 0 Y ❑ N
n Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this Per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
1- mil is issued,I shall not employ any person in any manner so as In
0 U hecome subject to the Warkets'Conspensn(iun laws of California.
Q. Date Applicant ALTER OR.ADD TO MECH. - 5.00 BUILDING
} to NOTICG•1'0 APPLICANT: If,after making this Cerlificme of hx-
F-. Z 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=CF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.RM.) 6.00 SEISMIC FEE
1 hereby affirm (hut there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,performance C.). of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM -
LendersNeme - HEATING UNIT(OVER 100,000 B.T.U.)8.50 fiU
Lender's Address ELECTRIC
• I certify that I have read this applicn(ion and state that tfc above VENTILATION EA (SINGLE) 4.00 -'
infomtation is correct..] agree to comply with.all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.Dr 100,000 B.T.U.) 6.00
hereby authorize rep •s'entatives of this city to enter uPan the BOILER-COMP(Over 100,000 BTU1 SEE FEE$CH. MECHANICAL -
above-mention r erly for inspection pu oses.
(We),agr to ave, indemnify n P harmless the City Of MISC.-' REFER TO ORD.
Cupertino ga' t Iia ilities j e , cysts and expenses which, PERMIT ISSUANCE 10,00 CONST.TAX
may i an way cru•, ga' st h ly in consequence of the
g. ga thi ,p mJ. MECH.CONT. . LIC.NO. - TOTAL ,
TOTAL
Signa p leant/ n clor e
OFFICE COPY - - -.