11692 • APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
EDILOINc �Su-t �-J APPLICATION & PERMIT
DRESSk
11692
� �0 YWL Lw BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNIE'S PLAN CHECK VALIDATION
y. NAM J/ QTY. ELECTRIC PERMIT FEE
Q�QI 1��/ 'NONE
CONTRACTORS gZgf. 4$b UTLETS-SWITCHES-RECEP 10.00/1.00
NA e
_ LIGHTING FIXTURES 10.00/1.00 /0
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ADN ACTOR'S
OO Ess APPLIANCES 4.00
C
PANELS 10.08DATE OF APPLICATION
On
ARCHDECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINE
Llc,No. SIGNS TRANS. 3.00
ARCH.OR END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDHEss
�Q- ZIP EMP. METER OR POLE INS. .00
ADDRES -NTS MOTORS SE H. n _
2.3-< JIL (L SERVICE CHANGE In .00 W
o o LICENSE CONTRACTORS DECLARATION ')
a u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D i Professions Code,trny license um
full f c cF
,e D`�3- License Cl er
e( O Lic.Numb ❑ ❑
0 w H 0. Date Contract9r -
Y 2 ¢ OWNER-BUILDER DECLAR TION BUILDING PERMIT
-SE 0 a U MISC.- REFER TO ORD INFORMATION
w3 LL F 1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
H LL 0`� Law for the following reason.(Sec.7031.5,Businessand Profusions PERMIT ISSUANCE 10.00 /0 ,
Code:Any city or county which req uires a Permit to construct,alter,
rt 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEF qq (^/
- 0 u raluires the applicant for such permit to file u signed statement that TOTAL per0 PERMIT TO
A whe is licensed pursuant to the provisions of ntmct°r's the CoLicense
m
H z Law 9(commencingwith Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 7031.5
STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).)'.
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for yak (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 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for salt.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 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
❑ 1,as owner of the property,am exclusively contn cling with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL 70.
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 projects with a eonlraemde)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2008/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W(VENT 6.00
reason
Owner Date WATER SYSTEM' 5.00 ACC.OATE ACC.FILE NO.
W'ORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sel Ginsom. ZONING ENG.SITE NO.
or certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company.
0 ❑ Certified copyis h erebyfutushed. FIRE SPRINK ENERGY T-24
Z Z EC Certif copy is filed iih the ci y in anti division. MISC.- REFER TO ORD. ❑ ❑ E] ❑
O Applicant V N Y N
F- y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
CER IF ATE OF EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
CL o (This section need-not be completed if the permit is fYE]
one TOTAL ❑ N❑ Y ❑ N❑
0 Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Worken'Compensation Laws of California.
0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex
F = emptiom you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you most forthwith comply with FEE
CJ such provisions or this permit shall he deemed revoked. AIR HANDLING PODGF.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10J=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOP ( Tri11 UCT 5.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 76110 B.T.U.) 6.00
Lender's Name
Lender's Address HEATI NGU B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above V ENTI LATION AV!WNG L ME) 4.00
information 6 correct. I agree to comply with all city and county BOILER-001'4(3 H:P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Oyer 100.000 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 0 '--� CONST.TAX
may in any way accrue against said City in consequence of the
gran of this permit. MECH.CONT. LIC.NO. MECH.
O z TOTAL ��oz TOTAL
St nemr o(Applicanl/Contracor Dal
. . OFFICE COPY