09688 (2) APPLICANT TO FILL MINFORMATION WITHIN RED LINES,- USE ALLPOINTPENONLY
BU I LDING'PROJECT I DENTIFI IN - PERMIT NUMBER
Bt,ILDING APPLICATION & P IT
ADDRESS p - 09688
• 7�.0��1/B�f C4l� UILDING -ELECTRICAL-PLUMBING-MECHANICAL '
OwrvER's _ PLAN CHECK VALIDATION
NAME ^ OTY, ELECTRIC PERMIT FEE
• Gf � Cr PRONE .
CONTRACTOR S
' E _ UTLETS-SWITCHES=RECEP 10.00/1.00 d'e
Ll Q YI L uc.ND, I+713 a-A LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
OORE55' e
\{' PRO.rC oj�Z/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO.
on SAH, 5t gS113 PANELS (OVER 200 AMP) 20.00 t,�0
ENGINEER
TIC.Na. SIGNS TRANS. 3.00
AARCH.OR
DDRESS ENG. SPECIAL CIRCUIT '5100 PERMIT VALIDATION
ZIP - EMP.•METER OR POLE INS. l20.00 q `
APPucSNr's - - .MOTORS P EE SCH. f//!�- _f.�•Jr�,�J
ADDREss �- -
» SERVICE CHANGE .00
r
O o .LICENSED CONTRACTORS DECLARATION TEMP,POLE .00 7
a U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
in w (commencing will,Section 7000)of Division 3 of the firmness end
¢ I BLDG. ELECT. PLG. MECH.
F N i Precessions CoH't�,yvl my license is in full fr nYe '.'3
z0 im o Licens1e Class y- 1 U Lin.Number T , _ ❑
r
Date Contractor ZI
Lr x E BUILDRIG PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
A o>v _ - - _ _ INFORMATION
x ; y I hereby affirm Oat I am exempt from One Contractor's Lifense MISC.- REFER TO ORD
wness VALUATION $/FT.
� tLOj Law l:An city or countywreashihc. uirers permit to
Professions PERMIT ISSUANCE 10.00
m� Code:Any city of county which structure permit m is mean alter, -
¢ 2 ¢ p improve,demolish,or repair any structure;prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n wo¢ requires the applicant for such permit to file a signed suntaitnt that TOTAL :! PERMIT TO
m�, lie is licensed pursuant to the provisions of the Contractor's License
rz>0 Law(Chapter9(commenciagwithSectiun7000)oflAvision3ofthe ELec
¢ Business and Professions Code)or that he is exempt therefrom andDTV. PLUMBING PERMIT FEE
1 i o
¢ 1- m the basis for the alleged exemption.Any violation of Section 703 L$ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant
n a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or myemployees with wages as BACK FLOW PROTECT. DEVICE 4.00 - OCC.GROUP RES.UNITS
Heir sole compensation,will do the work,and the structure is not
intended or offered for salt (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 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered 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 (EA.) 2.00
builder will have the burden of proving that he did not build or inn- BUILDING USE
prove for purpose of se INDUSTRIAL WASTE'INTER. 30.00 RES IND CON PB Onli,
❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively cmntracling 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 docs not apply -
to an owner of property who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts 1'nr Such projects with a contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.2008/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
U. I am exempt tinder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
ason
Owner 'Fate WATER SYSTEM ' 5,00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy Ilse&W-191 Lany e.C-33 01�����
Policy er 0:Larryµ7 J
O *A Certified copy is hereby famished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifie co y is filed it One city inspection division. MISC.- REFER TO ORD.
O App Fein�� Y N❑ 'Y C]
N❑
F- �+' PERMIT ISSUANCE - 10.00
LU - CERTIFICATE OF EXEMPTION ION PROM WORKERS FLOOD ZONE A.L.LLC.
W > COh1PIiNSATION INSURANCE; PLG.coNrR. LIC.No. PLG.
2 (This section need Tattoo, completed if Illi; permit is for one TOTAL Y❑ N❑ Y C] N❑
hundred doff rs(b 100)or less.)
O
I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued, I shall not employ any person in any manner so as to
O ad become subject to the Workers'Compensation Laws of California.
Q_ Date ApplicantBUILDING -
' >_ to NOTICE TO APPLICANT:-If,after... king this Certificate of nix- ALTER OR ADD TO MECH. 5.00
Z emption,you should become subject to the Workeri 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 10000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,OODGEM.)-6.00 SEISMIC FEE• -
I hereby affirm Ilial there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Pmfonnance of the work for which this permit is issued(Sec. MICROFILM
3097,Cw.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT 100,000 B.T.U.)9.50 q/
Lender's Address ELECTRIC
I certify thea I have trod this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n cornet. I s Re to comply with all city and county `PLUMBING
ordinances and correc laws relating m building all
city uction,and Co'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 love,imo00 BTU)BEE FEE$CH. MECHANICAL
abovrmentioned property for inspection purposes.
(We) agree to save, indemnify and keep hmu ess'the'Cify of MISC.- .REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue ag nsI said Cily in c uequence of the
ting (this permit (1 MECH.CONT. LIC.NO. MECH. -
7 cf TOTAL TOTAL
ngn pli n/Co
lure s f Apntractor Date '
OFFICE COPY -