10870 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION, PERMIT NUMBER
amLOING A07R'{ co ;e/ Or, APPLICATION & PERMIT 1 08 1 O
ADOR
CE55 e,_b-hb G'A SOI BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME�y/'Q y/ D&4-11y aS3-7355' QTY. ELECTRIC PERMIT FEE
Qdy PHONE
ANTHAcio 's
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
N
LIC,NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
RcmiECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
LIC.NO, SIGNS TRANS, 3.00
ADDRESS c"D SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH. (J
ADDRESS
SERVICE CHANGE 20.00
u�+oo LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that 1 am licenxtl under provisions of Chapter H !ISS 'NCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Fw i Professions Code,and my license is in full force and effect El ED]0 m- License Class Li,Number
Z w Date Contractor
a >! -+ BUILDING PERMIT
Ie ¢ ¢ OWNER-BUILDER DECLARATION
c d u INFORMATION
E
w LL N 1 hereby affirm thin I um exempt from the Contractor's License MISC.- REFER TO ORD yq LUATION $/FT.
u0¢ Law for the following Hessen.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
y0� Code:Any cityorcounly which requires a permit to construct.alter,
ac a, ¢ Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
u w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
FZ >0 Law(Chapter 9(commencing with Section 7000)of Division 3 of the - 6ir- L
¢ Business and Professions Code)or that he isexempt therefrom andQTY. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a3 - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 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
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Ser. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA, ®.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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- S 6, b `
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 T E 1
.1iimprovement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER ( A.) 2.00 ,
bulder will have the burden of proving that lie did not build or am- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. RES IND CON PB Diner
❑ 1,as owner of the properly,:un excl¢sively coninte ing with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 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 project'with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dal• - _ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DEARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Iab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ZC] Certified copy is fled will, the city inspection division. , MISC.- REFUR O ORD.
0 Applicant Y ❑ N❑ Y ❑ N❑
y CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 O FLOOD ZONE A.L.U.O.
Lal �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O This section need not be completed if the permit is For one TOTAL 6 Y❑ N Y -1 NE)
Z) Z hundred dollars($100)or less.)
0 O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mit is issued, I shall not employ any person in any mannersoasto
0 w become subject to lire Workers'Compensation Laws of California. BUILDING
y Datc Applicant ALTER OR ADD TO MECH. 5.00
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00 Lfro° PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVERIO,000C.FM.I (a-:OO ' SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH -00
the performance of the work for which this permit is issued(Scc. MICROFILM
B.T
3097,Civ.C.). HEATING UNIT(TO 100, .U-) •n
Lender's Name HEATING UNIT(OVER 100,0 .50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGE •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(3 H.P.or 100,000 B.T.U.) 6.00
Hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
e
abovmentioned property for inspection purposes. s '
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costsand expenses which' PERMIT ISSUANCE 10.00 e2 CONST.TAX
may iii any way accrue against said City in conspyuence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
(syr-�_ 9�.�L a-s-86 TOTAL TOTAL a
Signature of pplicam Contractor Uale
ICE OFFCOPY