10078 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION I BUILDING APPLICATION & PERMIT AooRFRR Wo-0 (a RIS �50,3 Dp BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10078
ry..ER. PLAN CHECK VALIDATION
1 /'OTYIAS �S a55-5W8 OTY. ELECTRIC PERMIT FEE
PHONF OLA Jl7CJ
CONTRACTOR
UyA E 1 1-� UTLETS-SWITCHES-RECEP 10.00/1.00 ,
lAk V c--winIT LC.No. � LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SIIJ�20113hPPLI ANCES-RESIDENTIAL -4.00
AD Ss
1 Q PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADORERS ENG SPECIALCIRCUIT S.00 PERMIT VALIDATION
elp TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH. -00W
SERVICE CHANGE 20.00 ' �j,
'.02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Y�-"
M L,u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DA'J///1/E
z "' (commencing with Section 7000)of Division 3 of the Business and
Ji PfO(fR51005 COdC,�rl�d mya ' rR IO full(Or . ( ;' BLDG. ELECT. PLG. MECH.
I, o�, - License q_.�OIL,.f,ic.Numb
9 w H w Dale Conlraosor no
4 IF M ec OWNER-BUILDER DECLARATION BT BUILDING PERMIT
w O Cup INFORMATION
w ;e y I hereby affirm that 1 am exempt from the Contractor's License MISC.- FER TO ORD
LOQ Law for the following reason. 7031.5,Businessind Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
r Code:Any city or county which requires a permit to construct,alter,
L C.C TR. LIC.NO.
W 4 $O improve,demolish,or repair any structure,prior to its issuance,also ELEC. �^
O it requires the applicant for such permit to file a signed statement that. HePTOTAL/st NTl.f! ERMIT TO _ I
L w m w he is licensed pursuant to the provisions of the Contractor's License Y,�LA
z ¢
L a
w(Chapter 9(commencing with Section 7000)of Division 3of the
f 4 C Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant loacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,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 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 Ra FT.FLOOR AREA TOTAL ACREAGE
•
,men"amself re
not hrough
own employees,for sale.
If,ed(hat however,
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems are nor intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BU1401 JG 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
❑ I,as owner of the property,am exclusively contracting with ❑ Cl ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
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 contractorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's such
License Lew.
D lam exempt under Sec.-,B.&P.C.for this
WATER HEATER W/VENT 6.00
reason
Owner Dam - WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-iname. ZONING ENG.SITE NO.
or a certificate of Workers'Compenvaion Insur ce,or a certified
copy therl!qq[[yy..�(g,ao--as3����pp,,,, ). 1 r ��(.�1�6�I,-.��1�,t ,
Policy NOA1S�Si1W, 1'.
0 ❑ Certifi deo y iehenm f rnished.
Z Z �Cer(1fie �J i1 ms ection division. FIRE SPR INK ENERGY T-24
O Ippfieont ` OPIyI L '1'lYS�7"}I MISC.- REFER TO ORD. y❑ rv❑ r ❑ No
H CERTIFICATE:O?EXEMPTION FROM WORKERS" PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
11J 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ I Y❑ N❑
D Z hundred dollars IS 100)or less.)
L) O I certify that in the performance of the work for which this per- CITY. 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 Workers Compensation Laws of California.
a Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this CertiOcate of Ex
F -
2 empium.you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 =C.F.MJ, 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OV 1 .M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WIT CT) ly
the performance of the work for which this permit is issued(Sec. III MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100, 6.00
Lender's Name HEATING UNIT 10 0B.T.11'9.50
Lender's Address ELECTRIC .
I certify that I have read(his 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 H.P.or 100,000 B.T.U.) 6.00
.hereby authorize rcpresentalives'of this city to enter upon the BOILER-COM 10 r100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. -�
(We) agree to save, indemnify and keep harmless the City of I REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT IS UA CE - 10.00 %� CONST.TAX
an
may in, y way accrue against said City in consequent of the
g an( This er it. MECH.CONT. LIC.NO. MECH.
p USI RO TOTAL //_- TOTAL 3a
gat re of Applicant(Contraclor to (U
OFFICE COPY