7160 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILAPPLICATION & PERMIT
ADDRESS L
x 10360 41501. KO BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 160
DING
OWNERS PLAN CHECK VALIDATION
�1C NC, It OTY. ELECTRIC PERMIT FEE
A1�171fN�jx:'IC vISDNE7 2' y7G
CONTRACTORS , OUTLETS-SWITCHES-RECEP 5.00/1.00
= 13 / LI; A94 -
LIGHTING FIXTURES 5.00/1.00
\ rorvTRAcaoRs S�1Y sTUt�i PPLIANCES-RESIDENTIAL
DDRESS 4.00
A
I C N1?511'"4,' S rTOONE 1 7'f-I// PANELS f 5.00
DATE OF APPLICATION
ARCRtTECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
moo Ess ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. I '
ADDRESS
SERVICE CHANGE 10.00
wO o LICENSED CONiRACI'ORS DECLARATION
¢ U I herehy affirm that 1 am licensed under provisions of ClmPler 9 ISSUANCE DATE
a w Icum nu�ncing with Section 7000)of Division 3 of the Business and BLDG. ELECT- PLG- MECH.
m'a' Professions Code m1�J cumse is in full torr an e ❑ ❑ ❑ ❑
z o u, License Cla s '+ Lic.Nmnber x+
o F�0 Dale ' Comrvctor_
¢ u s BUILDING PERMIT
OWNER-BUILDEROECI,ARA'1'ION INFORMATION
MISC.- REFER TO ORD
w3:
3 u r 1 hereby allinn that I am exempt from the Contractor's License VALUATION S/FT.
Fu Oj Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any cilyor county which requiresapermit toconstruct,aIle"
¢ ¢o improve,demolish,or repair any structure,prior to its issuance,alSo ELEC.CONTR. LIC.NO. ELEC.
0 ¢ requires the applicant for such permit to file a signet)statement that TOTAL PERMIT TO
e w m a he is licensed pursuant m the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Il�Po/R wA-�CR�i 9�f,
E O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ ro the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a _ by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(SS00).): 1
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT:DEVICE i 2.00 ora.GROUP RES..NITS
their 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. 4.00
Code:The Contractor's License Law does not apply to an owner of
pmperly-Who builds or improves there..,and who does such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsaye not intended oroffered for el,IL however.the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-If GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builder will have the burden of proving Ihat lie did not build of int- . . .
'I RES IND CON PB Other prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
CI I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
A 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 Contractors License Law does not apply
j to:In owner of property who builds or improves thereon,umd who LAWN SPR INKLERS-OVER 5(EA.) 1.00
contractire Cots ctoor r'shcenects Lwithacontractogs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE AGC.FILE No.
WORK ERS'COMYENSAI'ION DECLARATION WATER TREATING EQUIP, 4.00
I hereby infirm that I have a certificate ofconsent to self-insure. ZONING
or a certificate of Workers'Compensalion Insurance,or a certified ENG.SITE NO.
ropy the, S, ;; 0,L.b.C.). S /A TA Fu n
I'olivy No. 0nnpany
EI Cenilisd copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifiedy ¢ ed with the city inspection division. MISC.- REFER TO ORO.
I"" O\ Applicant Y[JN❑ Y E] NE]
y CERTIFICATE Oh EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU > ''COMPEN,SAUION INSURANCE PLG.CONTR. LIC.NO. PLGCL . v❑ NE] v❑ N❑
Z IThis Suction need not be completed if the permit is for one TOTAL
hundred dollars(S 1001 or Icss.)
L) O 1 certify that In the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- ..nit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 ED Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} W NO'FICE'1T'0 APPLICANIf,alter making this Certificate of E
F, Z enlption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONsrRUCEION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 5.00 SEISMIC FEE S0
I hereby affirm that Iherc is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the 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 HEATING UNIT(OVER 100,000 B.T.U.)7.50
lender's Address ELECTRIC
I certify that I have read this application and state that Ilse above VENTILATION FAN (SINGLE) 3.00 -
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.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
s ahuve-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in an way accrue agams(,said City in consequence of the PERMIT ISSUANCE 3.00
gr:ln Ih�p it. Jl � MECH.CONT. LIC.NO. TOTAL TOTAL a �j
/ 'Mature of Applicant Contractor Dale
INSPECTOR COPY