11757 - I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
nooa11N // O.CIP Gnc! 1111 l APPLICATION & PERMIT 11757
�\ /^•_ 4 r / ,{ ( �/� BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S /�C>tl y _. -- PLAN CHECK VALIDATION
-� "AME G/'e�O/'y Com/UU� L+IF,. PTV, - i?- ELECTRIC PERMIT; FEE'
�veoNE S°�$ •�1CT[� �
•
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
uC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 26.OD
OR PLAN CHECK FEE P.C.N0.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
ADDRESS
-{ xlr EMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. Wv
SERVICE CHANGE 20.00
X00 LICENSED CONTRACTORS DECLARATION P�•t ��/,�' l
rt 0 u I hereby affirm that I am licensed under provisions of Chapter 9 IS DATE
y a S (commencing with Section 7000)of Division 3 of the Business and BLDG, EL�, PLG. MECH.
H w Z Professions Code,and my license is in full force and effect, r ❑', ❑ ❑ ❑
0 i m o License Class Lic.Number
Date Contractor
Qyf
¢ ¢w¢ OWNER-BUILDER DECLARATION .l �j8U1LDIN PERMIT"µ==„
A o a o REFER TO ORD ...INFORMATION;-. '
w LL H I herebyaffirm that I am exem t Non,the Contractor's License MISC.-
P VALUATION
F LL o j Law for the following reason. 7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit toconstruct,alter,
2 Q 0 improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
- 0 u requires the applicant far such permit t0 file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractors License •-�Cf(C G.I U L
F ¢
Law(Chapter 9(Commencing`*'it h Section 7000)of Division 3 of the � 't ; � � viii 4 ''y _ � V�
_ Business and Professions Code)or that he is exempt therefrom and QTY: yr+ ! PLUMBING PERMIT. ,t. .N FEE A - o < Gd
¢r o the basis(pr the alleged exemption.Any violation of Section 7031.5 v':, �.#,.4N.,}.w TG,-:' „ c t. }� STORIES TYPE CONSTR.
.`t. a. of not mom than fby Sy applicant ive hunr a dred dolllars(SSOOubjects the jp ant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
❑ I,as owner of the property,or my employees with wages as
BACK FLOW PROTECT. DEVICE 4.00 Dee.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for salt(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
,1 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 SO.FT.FLOOR AREA TOTAL ACREAGE
„ himself or through his own employees.provided that such improve-
'+' menti are nobiRRtended or offered for sale.If.however,the buildins GAS-EA.SYSTEM-11NC.40UTLETS 6.00
< or improvemerttIir sold within one year of completion,the owner-
' builder will have the burden orproving that he did not build OTIM- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILOIrvNuSE
P 6 RES IND CON PB Other
• pr v for purpose of Jim p INDUSTRIAL WASTE INTER. 30.00
1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
lice d Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
s and nefempos Code:The Contractor's License Law does not apply I
tD an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.( 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contraci s License Law.
❑\ A ' u �SP.0 for th
�.. . is WATER HEATER W/VENT 6.00
masob L
OWnCn Date WATER SYSTEM 5.00 ACC.DATE Ace FILE No.
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
I heivby affirm that I have a certificate of consent to self-
insure. ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lab C.).
Policy No. Company
O ❑ Cerrified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified Copy is filed with the airy inspection division. REFER TO ORD.
0 Applicant MISC. YE] NE] YE] N
� N CERTIFICATEOF EXEMPTION PRONI WORKERS' PERMIT ISSUANCE 10.00 vLooD ZONE A.L.uC.
LLQ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v ❑ N
CL 0 (This section need not be completed if the permit is for one TOTAL
Z hundred dollars(SIOO)or lcss.l
U O I Certify that in the performance of the work for which this per, GTV• 'MECHANICAL PERMIT ot FEE FEE SUMMARY , ,
?. LL 1- mit is issued.I shall not employ any person in any manner so as(o ;+:
OW become subject to the Workers'Compensat ion Laws of California. BUILDING .f Z•
_ Date Applicant ALTER OR ADD TO MECH. 5.00 .S�
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, von must forthwith comply with FEE
U such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 QF.M.) 4.00
•'' CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE '3
1{ 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
'1 3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 I PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city W enter upon the BOILER-COMP (Over 100,000BTU1 SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep liannless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMITISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the r
Ant tHillgdf,�his nnil �� MECH.CDNL LIC.NO. MECN. J �r
i ,/c•,: -- /=f/](�'., TOTAL TOTAL /
ignature of Applicanticontractor Date
p'-1rE Dy