11068 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 110 6 8
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
AM OTY. ELECTRIC PERMIT FEE
�OnE PHONE_4� I
co TRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
Q\\ C�kT1(�ls uc.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS-10319
3 n ' APPLIANCES 4.00
s \J
ADD
PHO1I PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00
ENGINEER PLAN CHECK FEE- P.C.NO.
OR
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS '
SERVICE CHANGE 20.00 O� h/(1r
Doo LICENSED CONTRACTORS DECLARATION L l'
4o f to
u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANC DATE
2 z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r 0.i Professions C+d nJ se is in full f ❑ ❑ ❑
2 D y License s ota
Numb
Q Z � w Dutc CConctor
a x BUILDING PERMIT
E m w u` OWNER-BUILT DEc1.ARATIo INFORMATION
x D°' E_ I here affirm that I am exean t from the Contractor's License MISC.- REFER TO ORD
e 3 a. y p VALUATION
r LL o j Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to c milact,Lith",
SE a Q Q Improve,demolish,or repair any structure,prior to BS Issuance,also ELEC.CONTR. LIC.NO. ELEC.
n S:Do u requires the applicant for such permit to file a signed statement that TOTAL ±ERMIT 0
atm he is licensed pursuant to the provisions of the Contractor's License
z < Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D, Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
R F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
d g; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -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 OCC.GROUP RES.UNITB
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. 5.00
Code:The Contractor's License Law does not apply to an owner of
. property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedOroffered 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-EASYSTEM-OVER 4(EA.) 200
builder will have the burden of proving that h . . .
a did not build or im- BUILDING USE
prove for purpose of sale.): INDUSTRIAL WASTE INTER. 30.00 RES IND CON USE,
Omer
❑ I,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:']'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractot(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ouc Contractor's License Law. TRACT NO. PARCEL NO.
❑ I ala exempt under Sec. ,BAP.C.fur this WATER HEATER W/VENT 6.00
mason
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have R certificate ofeoosenl to self-insure, ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance,or a certified
copy th�gx�(�(. C.).(� ,� f••�
Policy h M%IW�i1.LF _ _
❑ Cerli lied copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 Cer I rs h g1 c ty inspection division.
O PPII antSotkl llR� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
cc T CERTIFICATE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
W > COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL ('Phis se clean need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ N❑
2 hundred dollars(SIOO)crIess.) ^^,,
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PEF(�AI+'I'�' , FEE FEE SUMMARY
LL I- mil Is issued,I shall not employ any person in any manner so as to W ,
Uher oe subject to the Workers'Copensation Laws of C.lifomie.
Ed
mm
Date Applicant ALTER OR ADD TO MECH. ' :00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Fx-
♦- ? eruption,you should become subject to the Workers'C'ommensation APPLIANCE 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
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance Of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. H EATI N G U N IT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)9.50
Lender's Address . ELECTRIC
• 1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
Ordinances and state laws rclating-to building construction, and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 6.00
hereby authorize representatives ec ofthis city enter upon the
nsp
above-mentioned property for inspection BOILER-COMP (Can,100,000 BTU)SEE FEE SCH. MECHANICAL
hipurposes.es
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in co a, of the
g a ' of this permit I KA MECH.CONT, TIC.NO. MECH.
ig are of Applicant/Conlnctor
UR11 TOTAL/ �� TOTAL
OFFICE COPY