10080 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 10080
ADDRESS ^ � \ .
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ..,.,.,•d •ig,x�;�: i,N::,;.r".Si:;.E<'ga.,,:4.';::.'�aF�rg+i. ice•;. M1�i=i; .; PLAN CHECK VALIDATION
-1573 °TM' 'ELECTRIC PERMIT
PHONE 1 Ir/
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
�3Q"e �tSp�`WIQ LIc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR' - 1� 1 � PPLIANCES RESIDENTIAL 4.00
-
DREss s , 1
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP)
20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT rj,QQ PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
°w 0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 7��A
L)U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ya i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. I MECH.
Professions Cod , nd ense is in full fo
0 y o Licen a Lic.Numb r ❑ ❑ ❑
y j Date- Contractor s s$UIL'DINQi}PERMI
s W OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD INFORMATION
wa
3 a F 1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
a 0¢ Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
y m-J Code:Any city or county which requires a permit to construct,alter,
Q¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a M requires the applicant for such permit to file a signed statement that TOTAL PERM17 TO
x m" he is licensed pursuant to the provisions of the Contractor's License ,A
Z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the /"`
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
c the basis for the alleged exemption.Any violation of Section 7031.5 nA STORIES TYPE CONSTR.
a 3 m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O 1,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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT N0. PARCEL NO.
❑ 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-
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate
�fof�Workers'Compen(saation`Insuran or a�certified
copy thery4fjnnC�)• 4 L.t'i�l-tl'S T
Policy N t
0 Certifed copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Ce fl Is fil w't th cl�inspection division.
p App(cant 6A I(1 MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
10 CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o (This section need not be completed if the permit is for one TOTAL Y C] N❑ Y❑ N❑
Z hundred dollars(S 100)or less.)
W., spi;+»=*',<<;:- >. :qg _.A0X4Si- rsa .'-
U O 1 certify that in the performance of the work for which this per-
QTY. MECHANICAL'P T `. ;`,.'`,r," •;':FEE z ', +` EESMMAR
LL I- mit is issued,I shall not employ any person in any manner so as to
L) become subject to the Workers'Compensation Laws of California.
O a Date Applicant ALTER OR ADD TOM CH. -,5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
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
C� such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(fid ,000C.F. 00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OV . ) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WIT CT) 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
Lender's Address HEATING UNIT(OVER 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 is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,0008.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FE SCH, MECHANICAL /F00
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- R E O `
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE
VAJ
gra i of this permit. M CH.CONT. LIC.NO. M -
TOTAL a
TQTAL`-:.
$ij(nftture of Applicant/Contractor a /? -
OF CE COPY