17819 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT 1 DENTI FICA ION PERMIT NUMBER -
BuaolNc a A-I- _ APPLICATION & PERMIT 17819
NoILDIN
ORES/.r_ �I BUILDING — ELECTRICAL—PLUMBING —MECHANICAL
ONLN.E`R/'6�SJL�(� A PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
—. E ONE J
NAME Tons �mG�IOUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 10.00/1.00 _
AD.TnncTons PPLIANCES-RESIDENTIAL 4.00
AD.
u
PHONE i PANELS 10.00 GATE OF APPLICATION
ORCHI cT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .c.No.
ENGINEER
I.C.No. SIGNS TRANS. 3.00
ARCH,nv E "G - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zm EMP. METER OR POLE INS. 20.00 �..-I( —Cib
ADDRESS
A ` V W
ADDRESS MOTORS SEE FEE SCH.
SERVICECHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARA'I'[ON .39
iu Lherehy affirm tial I am licensedlunder provisions or Chapter 9 ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business andLECT. PLG. MECH.
D z Professions Code,and my license is in full force and effect.
z o — License ClassLie Numher S V a
O T H au Date ContractorT� p ' 1�✓U
21
P Y x •'�� BUILDING PERMIT
a � a OWNIiR-BUILDIiR DECLARATION
o a UINFORMATION
.1 hereby atlirn that I am exempt from the Contractor's License MISC.— f njORE`EER TO ORD I
wog law for the following reason,(Sec.7031.5,Busitussund Profession, . PERMIT ISSUANCE 10.00 r VALUATION S/FT.
Cade:Any city or county which requires a permit to construct,alter,
a, ¢ r ELEC.CONTE. LIG NO. ��/_ i�7,
a 0 improve,demolish.or repair any strucmrc,prior to its issuance,also ELEC. lJ/
A wD M r cuires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO
m a- he is licensed Wnuant to the provisions of the Contractor's License
sir Law(Chapter 9(commencing with Section 70001of Division 3 of t he CGTv:11
a Business and Professions Code)or that he is exempt thcmfrom and DTV. PLUMBING PERMIT FEE I�V—i l.i
re I$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any omethan five permit subjects $500).applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500)J: V—H
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and I'rolessians DRAIN$-FLOOR,ROOF,AREA,COND. 5.00 n
Cale:The Contrac W r's-Licenr
se Law does not apply to an owner of _ 6
property who builds or improves thereon,and who docs such work FIXTURE EMAA. 5. so.PT.PLOOR AREA ,OTA ACREAGE
himself a through his own employees,provided ev such improve- ` :5C2 /��`'K��
meats arc not intended or offered for sale.IC however,the building GAS-EA. 6. c'I
or improvement cat is held within one year of that
completion, the owner- GAS-EA. ( A
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDD$TRI R 3 RES' IND CON PB 9rM1eI
O 1,as owner of the property,am exclusively contracting with LD ❑ 0 El 1:1
licensed contractors to construct the project(Sec. 7044,Business LAWN SPR' - 1 5 0 - ASSESSORS PARCEL NO.
and Prodessions Code:The Contractor's Licenw,Law does nol apply
to an owner of property who builds or improves thereon,and who LAW INKLERS-
contracts for such proicris with a contructoos)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. B.&P.C.I'or wis WATER HEATER W/VENT 6.00 -
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORK ERS'COMPHNSATION DECIARA'I'[ON WATER TREATING EQUIP. 5.00
1 hereby alfirm that 1 have a certificate of consent to all insure, ZOrvING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.CJ.
Tilney No. C tpany
O ❑ Certified copy mreby furnished.
❑ ertifieJ c is filed wi the •fiy inspection.division. FIRE SPRINK ENERGYTN
ZO App1 OEMISC.- REFER TO ORD. Y[:] e� Y ❑ N�
CC _H v PERMIT ISSUANCE 10.00 �a FLOOD ZONE A.L.uc.
� IJG\Tli OP IiX1iM I N'IB N\O tKERS' � --
LU > COMPENSATION INSURANCE. . ' PLG.CONTR. LIC.NO. PLG. l Y[:j N� Y E] N
CL C I'rhis section need not br completed if the permit is for one TOTAL
hundred dollars IS 100)Or less.)'
U 0 1 certify that in the Performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL I-, mit is issued.I shall not employ any person in any planner so as to
U become subject lO the Worker,'Compcmution Laws of California. [jam
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING f'
} N NOTICE'DO APPIACAN9': If,aft,,making this Ccrtificmc of fix- .
H Z emption,you should become subject to the Workers'Compensation APPLIANCE . 5.00 PLAN CHECK
provisions of-the Ichor Co&, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 109MC.EM.) 6.00 SEISMIC FEE Ug
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) •5.00
the perfrmtance of the work for which this gout is issued(Sec,
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.DO MICROFILM5�
Lender's NamAddress
H EATI N G U N IT(OVER 100,000 B.T.U.)9.50 Q
Lender's Address ELECTRIC
. I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
®
ordinances
n correct. 1 agree to comply with all city and county BOILER-CO P(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING rJ'I
information
and swec laws rioting m building l city uction,and co and
hereby authorise representatives of this city es enter upon theabove BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
( hereby entioned prepresy forvesp ofth i purposes. '
(we) agree to e, indemnify and keep harmless the City of MISC.- REFER TO ORD. t/
Cupertino again abilitin,judgments, costs and expenses which PERMIT ISSUANCE 10,00 CONST.TAX �aa T
may in any acerae ainst id Cily in corse a ace f the
a0tmg of s permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL It ,G
iSigoodureofAppB nt/ ontractor Date 5I
OFFICE COPY