11250 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU I LDI NG-PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING _ -`- APPLICATION & PERMIT
T ADORES.. _ E 11250
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S `--+v - dQ PLAN CHECK VALIDATION
.-}- NAME N' J . ELECTRIC PERMIT/ PHONE QTYIPIFEE 252
CONT ACTORS 3 Az.LE•G 43 9 OUTLETS-SWITCHES-RECEP 10.00/1.00
NAM �
ua No. LIGHTING FIXTURES 10.00/1.00
,L r,ONTRACTOR S n. F,8'L7 APPLIANCES-RESIDENTIAL 4.00 ,
f/i ! l�rlloNe PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20,00 lI PLAN CHECK FEE P.C.NO.
ENGINEER -
Lie No. SIGNS TRANS. 3.00
ARCH.OR ENG.. - SPECIAL CIRCUIT S.00 PERMIT VALIDATION
AuoHESS I - {
zit EMP. METER OR POLE INS. 20.00 '
APPIRLIC EASS
APPNTS
- MOTORS SEE FEE SCH.
`^
SERVICECHANGE 20.00 lA /
0 o O LICENSED CONTRACTORS DECLARATION
ec
U v I hereby affirm that I am'licensed under provisions of Chapter 9 ISSUANCE DATE
H G H (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELELT. PLG. MECH.
H N z rofessions Coys)I•,�ndj/nny license is in full for a e c}�
0 Z m I] icense class.. l¢_Lic.Number _f Zf_� ❑ ❑ ❑
Date Coulracmr
BUILDING PE IT
5 it w<U OWNER-BUILDER DbCLARATION INFORMATION,
-. woA MISC.- REFER TO ORD s
g u y 1 hereby 5ftrm that I am exempt from the Contractor's License VALUATION
H LLoa Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county`which requires a permit to construct,alter,
'p K ¢.0� improve,demolish,in repair any stmclure,prior Ili its issuunce,also ELEC.CONTR. LIC.NO. ELEC.
- o LL requires the applicant for such permit to file it signed Statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
Fri
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the yy
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE L"O
r e, the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicanito a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 -
of not more than five hundred dollars($500).): .
❑ I,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 Caw does not apply to an owner of
pro Perty who builds or improves hereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
T himself or Ihmugh his own employees,provided limi such int pnrve- ,
menta xrc not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
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 of sale.). INDUSTRIAL WASTE INTER. 30.00
C11,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
lie ...to contractors to construct the project(Sce.3044,IAhsiness 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
contracts for such projeen with a contractors)licensed pursuant to
tire Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO;
C1I am exempt under Sec. - ,B.&P.C.lot this WATER HEATER W/VENT 6.00 -
Irilo n
Owner Date WATER,SYSTEM 5.00
- ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent'to self-insure, ZONING
or'a certificate of Workers'Compensation Insurance,{or a certified ENG.SITE NO.
J 'opy Ihereof(Sec.3R00,Lab.C.L a
Policy Na. Company
O ❑ CerliOedcopyisherebyfunished. I IF FIRE SPRINK ENERGY T 24
zified copy is filed with the city inspection division. REFS 700RD.
PPlicanl SC. _ Y❑ IN❑ Y El N0
W CERTIFICA'IEOF Ii XIiMPTION FROM WORKIiRS' PE T 4fJ'UL 0.00 O FLOOD ZONE A.I.M.C.
LU - COMPENSATION INSURANCE PLG.CONTE LIC. PLG. ��.�
CL O ('Phis section need not be completed if the permit is for one 3 TOTA Y❑ N❑ Y ❑ IN❑
=) Z hundred dollars IS 100)or less.)
U O P certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- nit is issued,.)shall not employ any person in any manner so as to - _
0 - become subject to the Workers'' np Satisssr o x1� 'a ,
'.O a Dare APplieanl-, C(�� ALTER OR ADD TO MECH. . 5.00' BUILDING -
�- lD NOTICE TO APPLICANT: If,u l making 11, Certificate of fix. ,
F 2 emption,you should become soli ct to the Worken-Compensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply will, FEE '
U such provisions or this permit shall be deemed revoked. 'AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONS']RUCTION LENDING AGENCY ' AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE -
Vherehy'aftrm trial 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.).' HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender'sAddress HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC --
-
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4,00
information is correct.I agree to comply with all city and county PLUMBING O
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 (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We)agree to save, indemnify and k6ep'harmless the City of MIS..- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue Smarts aid C' in consequence of the PERMIT ISSUANCE 10.00
,an moll 's a MECH.CONT- LIC.NO. - MECH.
TOTAL TOTAL
igna re of Applicant/C ntraclor Dat.' - -
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