11073 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
So ILDINc APPLICATION & PERMIT
ADDRESS`\O \ \ /�1 11073
W 1 ,Vi BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
E (�I- DTV. ELECTRIC PERMIT FEE
�, 4 vHorvE '11(J'
CONTRACTOR'S
N,sNE UTLETS-SWITCHES-RECEP 10,00/1.00
U LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS �Q ^ APPLIANCES-RESIDENTIAL 4,00
AD ss C� 1 1s '
A
PH q4
PANELS 10.60 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
AOCOFESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20,00
w0 L LICENSED CONTRACTORS DECLARATION
u I/c/
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN E DATE
.N'Q a (consmencimg with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MEC
F w i Professions Cod an cense is in full f
G i m W Licen a Ci_ lysy Lon Numw ❑
Dam_S4->-1_ Contmcm
y 2� BUILDING PERMIT
tt 2 w M.
OWNER-BUILDER DBCLARA'fION - INFORMATION
o a MISC.- REFER TO ORD
E:
1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
H u_w j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
Krt Q 0 improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e w$m he is licensed pursuant to the provisions of the Contractor's License
FZQ Law(Chapter 9(consmenciag with Section 7000).fDivision 3 oflhe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis fur thl alleged exemption.Any violation of Seclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than Ove hundred dollars 155001.):
❑ I,as owner of the property,or my employees with wegesas BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
,their sole compensation,will do the Work,and the st,octure is not
Iinl2nded or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code\ Iso Contractor's License Law does not apply to an owner of
prdperty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.60 $0.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-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int RES IND CDN PB Omer
prove fors owner ofstheJ' INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the properly,nm exclusively contracting with
licensed contractors to construct the project7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
La
and Professions Code:The Contractors License Law does not apply
o owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 6(EA.) 1.00
contracts
hmete for such projects with a contractor(a)licensed pursuant to
the
tr Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.forthis WATER HEATER W/VENT 6.00
reason
Owner Dale ,. WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have acertificate ofconsent IOSCIGinsure, NWG
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ther C. rte`
Policy N Y
Q ❑ Certified copy is hereby,furnished FIRE SPRINK ENERGY T-20
/���/�Cerff��ffl��I4��ya�P Is •i(y 'nspecnon division. MISC.- I REFER TO ORD.
Z p AppBcant,.lsJ.tlll rr \� Y ❑ N❑ Y ❑ N❑
w CERTIFICATE;d EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0. 0 "(This section need not be completed if the permit is for one TOTAL Y❑ N[] Y [:] N❑
hundred dollars(S 100)or less.)
U 0 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
U became subject to the Workers'Compensation Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emotion,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 he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 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.). HEATING UNIT(TO 100,000 B.T.U.) B.00
Lender's Name H EATI NG UNIT(OVER ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I 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 13 HAor 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
ebovonsentioned property for inspection purposes. BOILER-COMP IOv r t BTU)SEE FEE SCH. MECHANICAL
`-�
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ^ CONST.TAX
may in any way accrue,against said City in consequence of llm PERMITISSUANCE' 10.00
g 'I )f this craft 'I MECH^.(CONT. LIC.NO. MECH.
USI TOTAL I900 TOTAL
are of Alplicant/Contractor D' I L)
OFFICE COPY •