11769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
14 mIILDING APPLICATION & PERMIT
ADOREss ssy �� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ' 11769
O'wN '9 7 PLAN CHECK VALIDATION
NA OTY. ELECTRIC PERMIT FEE
I J PHONE
1 CONTRACTOR'
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
GOTI".`' CU P,�IC. LIGHTING FIXTURES 10.00/1.00
•ooREss coNTRACTOR's - PPLIANCES-RESIDENTIAL 4.00
.! �a�a& L'
A�,IpNE 27/'-fZ PANELS 10.00 DATE OF APPLICATION
AARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEO
ENGINEER
Llc,No, SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
ADDAESS MOTORS SEE FEE SCH. . C y
SERVICE CHANGE 20.00 SEP
o¢ i
,02 LICENSED CONTRACTORS DECLARATION fs a of Cupor5
<i w I ereby affirm hal I am licensed under provisions of Chapter 9 CItY ISSUANCE DATE
N a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. ME H.
0 z Professions C1 a Y_ �fyny liceme is in full for i ff !o
ie.
09- License Cl _Y Yi Lie Number /
Uatc Contractorr1k LWen
a r BUILDING PERMIT
¢ ¢ a
OWNER-BUILDER DECLARATION INFORMATION
wm 1 hereby affirm that I am exempt from the Comrxtor's LicenseMISC.- REFER TO ORD
LL o ¢ Law for the following reason.(Sec.7031.5,Busin nand Proessions PERMIT ISSUANCE 1000 VAwATION SIFT.
vi Code:Any city or county which requires a permit to construct,alter,
aio¢ < improve,demolish,or repair any structure,prior to its nProance,also ELED.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
$w he u licensed pennant to the provisions of the Contractor's License
Fi > - Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or hat he is exempt therefrom and CITU. PLUMBING PERMIT FEE
¢ =$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a pemlit subjects he applicant too civil penally ALTER-DRAIN -WATER IEA) 500
of not more than Ove hundred dollars . .
(5500)): -
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
heir 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 FIXTURES-PER TRAP 5.00 60.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that arch improve. GAS-EA.SYSTEM-1.INC.40UTLETS 6.00
mems are not intended or offered for sale,If,however,he building
or improvement is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
budder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 NO CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ El ❑ IDlicensed contractors to construct he project(Sec. 7014,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 1 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves hereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contrthe Contract wchcenprojects Lwihacomracmr(s)licensed pursuant to SEWER-SANITARY-STORM EA.20011/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.For this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
• WORK ERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cettitleute of consent to self-inwre, ZONING ENG.SITE NO.
or a senifinte of Workers Compensation Insurance,or a certified
copy hereof(Seo.3800,Lab.C.).
Policy No. Company
RtAa�crlified
copy Is hereby furnished.
Z Z N Copy is OIeJ with Ibc city inspection division. FIRE SPRINK ENERGY TZa
F- t7 I _ MISC.- REFER TO ORD. r ❑ N❑ v ❑ N❑
cc - 1-.RT 117ICATE OF EX Ent PTI ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 c.
CONIPENSA
ION
W > IThis section need not bvTcoompleted Rif heEpcnnit n for orrc PLG.CONTR. LIC.NO, TOTAL Y E] NF] Y F] N❑
PIGCL
::) Z hundred dollars IS 100)or less.)
U O 1 Certify that in he performance of the work for which his per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
u
LL
U issuTOed I shall not employ any perarn in any manner so m Io
col y�s �lc�c�tq,the Workers'C mpensatinnyaw or Cllifomia.
i Uate � �Applieant �7r if £ I BUILDING
} to O F, APPLICANT: If uHer nuaking this Ccrtilicatc of Bx-
ALTER OR ADD TO MECH. 5.00
f" Z s tion,you should berome wbjed to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U arch provisions or this permit shall be deemed revoked , AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.ENU 6.00 SEISMIC FEE
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 isred(Sec. MICROFILM
3097,c'v.C.). / HEATING UNIT(TO l00,0008.T.U.) 8.00
Lcndcri Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information u comet. I agree to comply with u11 city and county BOILER-COMP(3 H.P.oT 100,000 B.T.U.) 6.00 PLUMBING
t ordinances and state laws relating to building construction, and
\ hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 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 ugain liabilities,judgments, costs nd expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any y deco a ag said y consequence of the
granting of - penn'L �} C MECH.CONT. p LIC.NO. MECH.
- i� _� -x1` �.(/+'Gt� LJ////� TOTAL ,� TOTAL
gna[urc ul Applicon Contractor Date > KK
OFFICE COPY