11698 . e.
„ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING - APPLICATION & PERMIT '
aoo Res�j �3 �I 6('S(•1 78n
1 ` 7 Ps n Lek �1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
I VM
NAIVER'a PLAN CHECK VALIDATION
.
SAO'C' r"V IJ3- s, a2 OTV. 3 h _- -- ELECTRIC PERMIT t _• FEE
vtn+K PHONE
rvAMEMAcaoRs UTLETS-SWITCHES-RECEP 10.00/1.00
�JLjK 1 TvkvLn q C4+i No. 7;267J J LIGHTING FIXTURES 10,00/1.00
CONTRACTOR'S - !J VA iTU5v1.
ADDRESS Jy /i-�µ �7-y )p APPLIANCES-RESIDENTIAL 4.00
�
�7S LN/tSV� SPHONE p O PANELS 10.00 DATE OFAPPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on . PANELS (OVER 200 AMP) 20.00
ENGINEER
' uc.No SIGNS TRANS. 3.00
ADDRRESS cmc. -SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIPITEMP. METER OR POLE INS. 20.00 )
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH, p/
_ - SERVICE CHANGE 20.00 -z-
F
09 LICENSED CONTRACTORS DECLARATION Ali,r10
v 1 hereby affirm that I am licensed under provisions of Chapter 9 1 - -
N2 w ISSUA CE DATE
¢w (commencing with Section 7000)of Division 3 ol'.the Business and.
r H z Professions Co d license is in full force'ld f��eerr�� BLDG. ELECT. PLG. MECH.
i O w - License I' Lic.Nmnber /�+�`�y
4 n r w Dalc Contractor
a Q w a OWNER-BUILDER DECLARATION BUILDING PERMIT
° MISC. REFER TO ORD ` ` INFORMATION
X g LL 1 hereby affirm that I oto exempt from the Contractor's License
w0 ¢ Law for the following reason(Sec.7031.5,Business and Professions
VALUATION .$/FT.
-w PERMIT ISSUANCE 10.00
E W t Code:Anycily orcounty which requires a permit to construct,alter,'
¢ ¢ ¢,O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. VVU
-w M requires the applicant ror such permit to file a signed statement that TOTAL
u w he is licensed pursuant to the provisions of the Contractor's License _ PERMIT TO
RzaLaw(Chapter 9(commencingwith Section 7000)of Division 3 oflhe
4 0 Business and Professions Code)or that he is exempt therefrom and DTV,. PLUMBING PERMIT ',-FEE /-
¢ F pN the basis for the alleged exemption.Any violation of Section 7031.5 °. STORIES TYPE CONSTR.
a 3 � by any applicant for a permit subjects the applicant boa civil penalty gLTEfl-DRAIN&VENT-WATER (@At) 5.00
of not more than five hundred dollars($5000.) -
❑ 1,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 docs such work FIXTURES-PER TRAP 5.00 SO.Fr.FLOOR AREA rOTAI 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-I INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES NO CON PB Other
❑ 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 Lew does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS- 1EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License law. SEWER-SANITAR V-S 0IMEA.200ft/10.00 --TRACT No. . PARCEL No.
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER �V , Y 6.00
Owner Date WATER SVSTEM "' 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING U 5.00
I hereby affirm that I have a certificate of consent to self-Insum,
or rjl fie .,kers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
"O
800,Lab.C.).
not Icy No, Company h
❑ Certified copy is hereby Turn ish ed. -
z 2 �% Certified _ FIRESPRINK ENERGYT-24
�y is led li�with the city inspection division.
Fp Applicant "7���t - MISC- REFER TO ORD, Y [] N❑ 'Yo N�
CC LO CERTIFICATEOF EXEMPTION FROM WORKERS' IPLG
ISSUANCE 10.00 FLOODZONE A.LU C.
LU
0 COMPENSATION INSURANCE LIC.NO. PLG. V(This sectidn need not be completed if the permit Is for one TOTAL �y " y( N Y N
Z hundred dollars IS 100)or less.)U O 1 certify that in the performance of the work for which this per- MECHANICAL PERMIT - FEE FEESUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to Q wbecome subject to theWorkers'Compensation Laws ofCalifornia.
Date Applicant OR ADD TO MECH. BUILDINGW- NOTICE TO APPLICANT: If,after making this Certificate of Ex- 5.00emptiod,you should become subject to the Workers'CompensationNCE 5.00 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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCYAIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMICFEE'
I 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(Sea MICROFILM
3097,Co C.L HEATING UNIT(TO 100,000 B.T.U.) 5.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
0 1 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-OOMP13 H.P.Of 100,000 B.T.U.) 6.00 'PLUMBING
ordinances and state laws relating to building wnstruclion, and
hereby authorize representatives of this city to enter upon the BOILER IOvnr 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, Indemnity and keep harmless the City of MISC.- `' REFER TO ORD.
Cupertino against,liabili des,judgments, costs and expenses which CONST.TAX
may in any yvay ecru -gains[ Said City in consequence of the PERMIT,ISSUANCE 10.00
granting o�is »il MECH.CONT. LIC.NO. MECH,
C• Qac` TOTAL TOTAL
Signature 'fA lien /Contractor Date
OFFICE COPY