9108 (2)_ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
--F
ADDRESS/O / r/ T Z T D , 9108
C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
1 OWNER'S PLAN CHECK VALIDATION
�"'Y NAME L4 PTV. ELECTRIC PERMIT FEE
MIKEEi✓DE25 E 2 S" -' �
PMOrvE
rciamERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
Or VlS / uc.No.a�/��5� LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S, APPLIANCES-RESIDENTIAL 4.00
ADDRESS osE a �F3-3�T7-
9 ouGc NE vE PHONE PANELS iQ.QQ DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR 0
ENGINEER
LOC.No. SIGNS TRANS. 3.00
ADDRESS Ervc' SPECIAL CIRCUIT 5.OQ PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0R
LICENSED CONTACTORS DECLARATION TEMP.POLE 30.00
a is i-i 1 herchy affirm that I ton licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BLD E EC - L M CH
F w z Professions Code nd my license is in full force a d effect.
.Q 0 o o Lieense Cless_�Lia Number _
H w� Date -+- b - Contractor01
F J �-
,a u s J BUILDING E MIT
¢ a OWNER-BUILDER DECLARATION
o a" MISC.- REFER TO ORD INFORM TION
w 3 LL H I hereby affirm that I am exempt floor the Contractor's License VALUATION
.. o¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 S/FT.
Code:Any city or county which requires a permit to construct.alter, - q�-D
Qto Q Q Improve,demolish,Or repair any structure`,prior to its issuance,also ELEC.CONTR. LIC.N0it . ELEC. �G•
w- 0 ¢ requires the applicant for such permit to DIC a signed statement that TOTAL PERMIT TO
ce U. he Ls licensed pursuant to sire provisions of the Con Uactoi s License
HZQ Law(Chapter 9(communcing with Seel ion 7000)of Division 3 of the
4 D
It and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ I_ o the basis for the alleged exantplion.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Li by any applicant for a permit subjects lire applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
,)fact more than than Ove hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their Sale compensation,will do the work,and the structure 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 FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such
improve-runts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 L'E'TS
or improvement is sold within one year of completion,the owner- GAS.-EA.SYSTEM-OVER 4 IEA.1 2.00 BUILDING USE
builder will have the burden of proving that he did not build or in,
prove for purpose ofsale'). INDUSTRIAL WASTE INTER. 30.00 IND CON PB ' Othe,
❑ 1,as owner of the property,um exclusively Contracting wills ❑ ❑ 1E . ❑
licensed Contractors to consauct the pmjccl(Sec.7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
r and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
'contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Conlmctor s License Law. TRACT NO. PARCEL NO.
O-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,
WORKERS'COMPF-NSCfION DECLARATION WATER TREATING EQUIP. 5.00
.y I hereby affirm that I have a Certificate Ufcemooit to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
.-F copy 3800, O
Policy No. CompanCom"Cyh'
❑ Certified copy is herby furnshcd. FIRE SPRINK ENERGY T-24
/+ Z Z 5j4 Certified y is filed will Or city ins tion division. MISC- REFER TO ORD.
O Appicunl Y ❑ N Y ❑ N❑
i ~ w ' PERMIT ISSUANCE
2CF R'I' JCATEOP EXEMPTION FROM WORKERS' n FLOOD ZO E A.L-U.C.
LUQ_ COMPENSWION INSURANCE PLG.CONTR. LIC.NO. PLG
EL . ❑ Y ❑ N❑
o (This section need nut be completed if the permit is for one TOTAL VNEI
T hundred doIIr,s(S100)orles,)
U O /
I Certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in anymanner so as to
O become subject to the Workers'Compensation Laws of California.
W lyase Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NO'I'ICIi '10 APPLICANT: If,after making this Certificate of Ex-
F 2 Cmption,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 IOpDDGF.M.) 4.00
CONSTRUCTION LENDING AG13NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE /
_ I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 /
flit perrll'orv.maMICROFILM
nee of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000g.T.U.) 8.00
Lender:Name HEATING UNIT(OVER 100,000B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l 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 relining to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Ower 100,1X10 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.-, REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' PERMIT ISSUANCE 10.00 CONST.TAX
nm
y in any way accrue against said City in consequence of the
granting oyyits permit I MECH,CONT, LIC.NO. MECH.
g, - �1 Roii.��/ �0�7�I TOTAL �j TOTAL/.,
i SIgnIE c lI App rcant/Con rector trate
INSPECTOR COPY