11263 C r ik, PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE RALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI Fi :ION --- PERMIT NUMBER
BUILDING APPLICATION & PtRMIT
E -DE� _ �� BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 11263
OWNER'S PLAN CHECK VALIDATION
. TV. ELECTRIC PERMIT ;''�; FEE,
NSE[l-Y C o�JOS 1 NE 2 25
CONTRACTOR'S
NA f� �j�7 OUTLETS-SWITCHES-RECEP 10.00/1.00
1 :! �C /^ / I / sec No. (,(J LIGHTING FIXTURES 10.00/1.00
r
[APPLIANCES-RESIDENTIAL 4.00
coN RAc
A 20X / V PHONPANELS 10.00 DATE OF APPLICATION
RRLHITECt PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
sec.No. SIGNS TRANS. 3.00
ARCH.OR
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
APPLICANT
sJ MOTORS SEE FEE SCH.
U SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
Is u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H<h (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Z o0 2 Professions Code ,dOnenu Oil full Io in ❑ ❑ ❑ ❑
w- LicenuC s (V/ Cont,Number L
9 m w Dau Lic.N mr -
BUILDING PERMIT:..^
M IS m a OWNER-BUILDER DECLARATION •`.IN FORMATION ra Irv;
MISC.- REFER TOORD
E
; H I hereby affirm that I am exempt from the Contractor's License
IS
Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which nequiresa permit to construct,alter,
G 40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
o I, requires theapplicantrfor such permit m file a signed statement that TOTAL PERMIT 70
a w m he is licenseddpursuant to the provisions of the Contractor's License _ �G-(y JIJf
z a Law(Chapterand
Professions
Code)or Section is exempt therefion o of the '+
i o Business and Professions Code)or that he is exempt therefrom and QTV. i+..''! ' PLUMBING PERMIT. _ j`•FEE -
in1 the bazis for the alleged exemption.Any violation of5ection 7031.5 . 'e'.:, :i.,::_ .`1 ��" `. - , 'o '- ~ I ':=4-• STORIES TYPE CONSTR.
n3 - by any applicant for a permit subjects the applicant Boa civil penally gLTER-DRAIN&VENT-WATER (EA.1.5.00 -
of not more than five hundred dollars(5500),):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce GROUP RES.UNITS
their Sore compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS.FLOOR,ROOF,AR EA,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
himself or through his own employees,provided that such Imp rse. SO.FT.FLOOR AREA TOTAL ACREAGE
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or unprovemenl is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.1 2.00 BUILDING USE
prove for 1,aso neeose curside.). RESINDUSTRIAL WASTE INTER. 30.00 ❑ I❑ EN PB❑ Other
❑ Las owner of the property',am exclusively contracting with
,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 properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for Ibis
reason WATER HEATER W/VENT6.00
Owner Date WATER SYSTEM 5.00 AOC.DATE ACO.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to wirins.1c,
or a certificate of Workers'Com ensatio Insurance. r a cel tried ZONING
p ENG.SITE N0.
copy thereof(!Sec.3800, pab.y T/it �i /.1 r//A//
Policy No.__Company..../- Il/UUL-ZP!!`I
❑ Certifi71CATEOFEXEMPTIONFROM
is rebyf ishcd. FIRE SPEINK ENERGY i�
Z Z ❑ Certifiy file 1 he ci nspeclion division. 24
F-' O Applicant MISC.- REFER TO ORD, v N Y Q NC
CZ CERT WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE - PLG.CONTE. LIC.NO. PLG.
D' O (This section need not be completed if the Permit is for one TOTAL Y❑ IN Y IN
::) Z hundred dollars IS 100)or less.) _
U O ,l certify that in the performance of the work for which this per QTY MECHANICAL PERMIT FEE
FEE SUMMARY
0 U mit is issued,I so t not rk Ploy any person in any manner so is m
O m become subject to the Workers'Compensation Laws o(California.
d Date Applicant ALTER OR ADD TO CH.PAP
5.00 BUILDING
>_ 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F' Z emption,you should become subject to tshahe Workers'Compensation APPLIANCE 1-(- ' 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with r
U such provisions or this permit ll be deemed revoked. AIR HANDLING UN � ^ 1 P00 QF.M.) 4.00 I FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVE 6.00 SEISMIC FEE
1 hereby affirm that there is a construction rending agency for EXHAUST HOOD ( DCT) 5.00 '
the performance y(I qa work for wqhich this rmit is issyd ec. MICROFILM
3097,nder's ,C.). i.'/��C1 A.�� HEATING UNIT(TO 100,000 B.T.U.) 8.00 ;;ELECTR
Lender's Name r Tf
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50IC
1 certify that I haveread this application and slatethat the above VENTILATION FAN (SINGLE) 4.00S, information is Correct.1 agree to comply with all city and county' PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorentionize representatives ins of this city to enter upon the 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mention ed prop, Inde inspection and keep harroses. MECHANICAL ] -�
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way acer gaigSl said City' in consequence of the PERMIT ISSUANCE 10.00 CID
grant ( hi roo n/ � MECH.CONT. LIC.NO. MECH.
YO TOTA 00 TOTAL
Signa a of Applican/Contractor Uare
OFFICE COPY