11066 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11066
TOORESS a,. • E \ rl/""
,h•.�tOl\ EY IBUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
V V-j��RorvE��-U ILa-�
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
E L�
uc.No. J LIGHTING FIXTURES 10.00/1.00
CONTRACTORS �Ip 1-X PPLIANCES-RESIDENTIAL 4.00
A ESS U 1 1
vHON PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS 200 AMP) 20.00
OPLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. llll.N'.'rN'
ADDRESS
SERVICE CHANGE 20.00 P ^�/
IDu¢ z ! d"
Foo LICENSED CONTRACTORS DECLARATION
v I hereby affirm that I am licensed under provisionsof Chapmr9 I (f' I UA .ATE
N¢ N (commencing will,Section 7000)of Division 3 of the Business and LD . e E J.: LG. MEC
F D z Professions C an cense Is in full ❑ ❑ t
z o - Licen'c Lic.Nnm�
Q z D Datc- Contract.
a x MM
13L' ERMIT
a w u OWNF:R-BUILUfiR UECLA RATIO INFORMATION
X3 LL N I hereby affirm thin I um exempt from the Contractor's License MISC.- REFER TO ORD
LLo ¢ Law l'orthe followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
-0J Code:Any city orcounly whichrequiresapermitioconstrucl,alter.
¢¢Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm w he is licensed pursuant to the provisions of the Contractors License
FZf
Law(Chapter 9(commencing with Section 7000).(Division 3 ofthe144.
- ¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢F p the basis for the alleged exe iplion.Any violation of Section 7031.5 BTO IES TYPE CONSTR.
e 3 N of annot morelicant(ore permit subjects
dollars(5500 applicant to a civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Cl I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that Such improve- GAS-EA.SVSTEM-11 INC.4 OUTLETS 6.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 2.00 -BUILDING USE
builder will have the burden of proving that h .e did not build or im- RES IND CON PB 011ier
prove for purpose of sale,). INDUSTRIAL WASTE INTER. 30.00
❑ I,as 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 property who builds Or improves thereon,and who LAWN'SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclorls)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Cl I am exempt under Sec...BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that I have a certificate of consent to sell-insure. ZONING ENG,SITE NO.
or a certificate of Workers'Compe tion InsuI •or a certified
copy thea �.
Policy `
Q O S,erl fi copy is h�1 ,mshcdl.' FIRE SPRINK ENERGYT24
Z Z t,/Cert�fis �t� Isys� nspection division.
Applicant 1/-11 ' 1MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
- CERTIf ICATEOFROM WORKERS'
111 > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
TOTAL Y❑ N❑ Y ❑ N
OL 0 ❑
CI section need not be completed i! the permit is for one
0 Z hundred dollars IS 100)or less.)
U O I Certify that in the performunce of the work for which this per- CITY, MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. BUILDING
Date-Applicant ALTER OR ADD TO MECH. 5.00
>_ N AppNO'T'ICE TO AI'I'I.ICANT. 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, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10, 000.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that 0mre is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify thud I have read this application and state that Thu above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP13 H.P,or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construcdion, and
hereby authorize representatives of this city to enter upon the BOILER- OMP 10 r 00 BTU) EE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MI C. TO D.
Cupertino against liabilities,judgments, Costs and expenses which PER T ISSUANCE 0 CONST.TAX
may in any way accrue against said UM 1 ,City in consequence of the
ra flhis ermit. MECH CONT. LIC.NO. CH.
V^1 1 1 ' TOTAL I TOTAL
'i tore of Applicant/ Detractor D to htl HO�i
OFFICE COPY _
II � .