8130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIF[CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
117 W ,llyiq�- loaqIlUILDING-ELECTRICAL-PLUMBING-MECHANICAL8130
S -' /� PLAN CHECK VALIDATION
" LrAvf1/ 04q OTY. ELECTRIC PERMIT FEE
_ vH°NE
NA"Md °iO S A'aUTLETS-SWITCHES-RECEP 10,00/1.00
IC.No. LIGHTING FIXTURES 10.00/1.00
h COW PPLIANCES-RESIDENTIAL 4.00
PHOry PANELS 10.00 DATE OF APPLICATION
RRCHITEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRRESS EKG
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
Avvuc4rvrs MOTORS SEE FEE
A 55
SERVICE CHANGE 20.000.00
O o LICF,NSCD CONTRACTORS DECLARATION TEMP.POLE 30.00
a u U I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
ii i (commencing with Section 7000)of Division 3 of the Business ar,
Q BLOO_ ELECT. PLG. MECH.
v
H w i P Oficaam,Cd in wense is in full force an e
z o u, - License Claxs Lia Number El ElO � H � Date Cmttmaor
a y C_O BUILDING PERMIT /
oc Sic
¢ O\ NIiI- ILDIiR UECLA RA I
a w v INFORMATION
W 5 LL 1- 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
.. o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which me cin s a permit m constnmt,alter,
¢ u, 2 improve,demolish,orrepair any structure,prion to its issuance,also ELEGCONTR. LIG NO. ELEC.
A
o B, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
m m he is licensed pursuant to the provisions of the Contractor's License
Fz> Law(Chapter 9(commencing with Section 7000)ofDivision3oCthc
a Business unJ Profes,ions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
E o the basis for the alleged exemption.Any violation ofSeclion 7031.5 STORIES
n; m byanyapplicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 '
their sole compensation,will Jo the work,and the st mature is not OCC.GROUP RES.UNITS
intended or offered for sale (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 F IXTUR ES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such improve-
merits are 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, - . -OVER 4(EA. .00 the owner- GAS EASYSTEM ) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
po,Ve for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND Pe Omer
O I,as owner of the property,am exclusively contracting with 1:1Elc N 0 11
licensed contractors to construct the project(Sec. 7044,Businexs LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR cEL NO.
and Professions Code:'fhe Contractor's License Law docs 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 contract.,(,)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tont exempt mldar Sec. ,B.&i'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of'co ent to self91�lii
c
Or a certificate of Workers'Compensation Insur nee,or a d ZONING ENG.SITE NO.
copy therm ( 3 00,Lab.C.).
14dicy Nn mpany
O ❑ Cetli (d Copy Whereby fano, FIRESPRINK ENERGYT24
Z z0 'pip p,I heJ copy is filed wi L cit ins coon division. MISC.- REFER TO ORD, y E] N Y [] NE]
rn (�J7E Cl:It I'I FI ixliid PfI(IN P OM iRh1iR, PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
LU > CONIP, 'SAIION INSURANCE PLG.CONTR. LIC.NO. PLG.
a_ 0 (This section need not be completed if the permit is for one TOTAL y❑ N❑ y❑ NC]
hundred dollars(51001 or IessJ
U O_ 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any Person in any rammer so a,to
OL) become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ fir NOTICE F0 APPLICANT: If,after making this Certificate of Ex-
F- z_ emption,you should become wbjcn 1n the Workers'ColnpensutioR APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this pemtit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 .F.M.) 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.) 8.00
Lender's Name HEATINGUNIT(OVER l00,000B.T.U.0.50 ELECTRIC
Lender's Add.•es
I certify that I have read this application and zlate that the above ENTI LATION 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 130ILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property or inspection purposes.
BOILER-COMP (Over t00,000BTU)SEE FEE SCH. MECHANICAL
I
(We) agree to ave, ind fiify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agai is Aliti ,ju humans, costs and expenses which CONST.TAX
may in any accnl agai t said City in consequence of the PERMIT ISSUANCE 10.00
anti gof permit. EC CONT. LIC.NO. MECH.
TOTAL TOTAL
ata of Applica t/CoRrac r 0J li /
IIIWECTOR Copy