3177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
III, I
c' BU LDI NG PROJECT I DENTI FICATI ON I vE MIT NUM R
BUILDING APPLICATION & PERMITe�
ADDRESS 3177
110 00 L BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
*4
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
vnonE 257.70
corvrnncroRs
NAME OUTLETS•SWITCHES-RECEP 5.00/1.00
SU SPRwcLT�x
LIC.NO.0 IID 0187/ LIGHTING FIXTURES 5.00/1.00
ADDESSTORS
R ' APPLIANCES-RESIDENTIAL 4.00
305 q40 `T PRONEq4ea-YX7Q
PANELS � 5.00 DATE OF APPLICATION
ARCHITECT 1.rl,�ws, C� 9stl ! SIGNS 6.00 PLAN CHECK FEE P.G Na.
ENGINEER rr•�4^ .NO. .
LIc.No. SIGNS TRANS. � 3.00
AARCH.OR
DDRESS ENG SPECIAL CIRCUIT S,OB PERMIT VALIDATION
IiP ITEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH. 1
ADD. S&� E _42 v� Il
.�uMG As H [JA SERVICE CHANGE 10.00
02 LICENSED CONTRACTORS DECLARATIONce
Kin
Q U U I hereby affirm trial I am licensed under provisions of Chapter 9 ISSUANCE DATE
yIL (commencing with Section 7000)of Division 3'of Me Business and
a g - BLDG. ELECT. PLG. MECH.
r N i Professions Code and my license is in full force and effect. ❑ ❑ ❑ ❑
Z o W Licanse Class=/6l Lie.Number 1-1•1-�r-s-
O Z r wo Date .7-.ay-$3 Contractor ga�.te.G:_Id.T�1H:t0
H � (,a. BUILDING PERMIT
1� r
•¢ ¢ w OWNER-BUILDER UECSLARAlION1e - INFORMATION
w ; IH I herehy affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
H u O J Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 �7 5/FT.
OF Code:Any city orcounly which requiresa permit to construct,alter,
/DOa, a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. i,,
, rc(Imres the applicant for such permit t0 file a signed statearent that TOTAL PERMIT TO
o. w m he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Z/1Jjartt 5PR1R1(1"i$
f 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
MH m the basis for the alleged exemption.Any violation of Seotion 7031.5 STORIES TYPE CONSTR.
La by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(SS001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their role compensation,will do the work,and the sticture is not
intended or offered for sale(Sec. 7044, Biatiness.and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
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 4.00 s0.Fr.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.Provided that such improve.building
mems are not through his or employeeffered for sule.lf•ed that sthebwlding GAS•EA.SVSTEM-11NC.40UTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or ins
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
O 1,us owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 . 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 cl ntructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
rea C1 I um exempt under Sec. ,B.&P.C.forthis WATER HEATER W/VENT 4.00
soR
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COA/PENSATION D17CLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy therupl' Sec. Lah.C.�T
Policy NoL r14', q,,.puny Jk(�a_ �Ia�at T!�$.e_
0 O CCtlit{is�Jr�q�y/yOyIs he cby Turn lsri d.
Z Z Jt Cc' If
f ith n city inspection division. FIRE SPRINK ENERGY T44
O Applicant MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
~ wPERMIT ISSUANCE 6.00
� - ICERTIFICA'fEOF EXEMPTION FROM WORKERS'• FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTH, LIC.NO. PLG.
d O '(This section need not he completed it the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
'U Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issiled.I shall not employ any person in any manner so its m
O w become subject to the Workers'Co npensation I.nws of C I coria.
U •^/
a
Date-Applicant_JLG7 o1lALTER OR ADD TO MECH. 4.00 BUILDING L� 00
} W NOTICI7 TO APPLICANT: If,Biter making this Certificate ' ix-
L
FZ emption,you should become subject to the Workers'ComPensalion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with .`
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE rW
„I hereby SIT,,,, that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of 0m work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name� �
Lender's Address 41A - HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
OrdinInfor alioces and slate laws relating m hulloing 1 city n,coction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property lot inspection purposes. BOILER•COMP IOvar 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep hunnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in It, vay accrue aga'nst said City in consequence of the
grants f IS'permmf MECH.CONT. LID.NO. MECH.
,��- TOTAL TOTAL �p70
Sig lalureof Applicant onlructor Ute
OFFICE COPY