10024 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL P
BU LDI NG PROJECT IDENTIFICATION
BUILDING 1•' APPLICATION & PERM[
ADDRESSBUILDING ��
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ADDRESS F�LTON V` y' ,�, ` O 7 1..1 4
S -ELECTRICAL-PLUMBING -MECHANICAL
�ERs � IhE `t LMR Offj aS70
PLAN CHECK VALIDATION
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pet
pp DTV. ELECTRIC PERMIT FEE
` t-0 N PRONE In
CONTRACTORS
NAME �J/� OUTLETS=SWITCHES-RECEP 10.00/1.00
_110 G( LIC,No LIGHTING FIXTURES 10.00/,1.00
CONTRACTOR'6
ADDRESS •}-�. PPLIANCES-RESIDENTIAL 4.00
F0o7-N/ _Loj)Pte\ PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK EE P.O.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCHADDRESS ENG. SPECIALCIRCUIT 5,00 PERMITvqX
ZIP EMP.METER OR POLE INS. 20.00 NOV
ADDRESS MOTORS SEE FEE SCH. 1'
SERVICE CHANGE 20.00 �y /� pD
'00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 000 Ci'/ of 1N p"no
Mut;
I hereby affirm that I am licensed under provisions of Chapter 9
i w ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D i Professions Code,and my license is in full force and effect. i O ❑ ❑
oi o License Class Lic.Number
m H Datc Contractor
a y J
¢ ¢ w a OWNER-BUILDER DECLARATION BUILDING PERMIT
ca ;e m I hereby allirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
u O j Law for the fotowing reason.(Sec.7031.5,Rusine s and Professions VALUATION S/FT.
- PERMIT ISSUANCE 10.00
vs Code:Any city or county which structure.
requiresa Permit to construct,,also
a ¢ ¢ p improve,demolish,or repair any itructurt,prior ro its issuance,also ELEC.CONTR. LIC.NO. ELEC.
rc O ¢ requires the applicant for such permit to file a signed statement that TOTAL,
w 9,� he is licensed punuant to the provisions of the Contractors License RMIT
H i r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i 4 o Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
ar the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n , by any applicant tura permit subjects S500).licam tea civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than!of hundred dollen(my em:
❑ I,as owner at the property,or my employees with wagesut BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will(S the work.and the structure a not DCC.GROUP RES.UNITS
intended or offered for sale se L 7044, Business and nProfessions
of DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's improv Law docs not apply to an owner of
property who buildsorimprovesthereon,
rvidwho docssuch work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through de own empld for sale.provided thus such ins ilding
or nts Improvemenotnt tended or wthin on yearoIf.howetion the the ower- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or bnprovll have
is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the ll Nen of proving that he did not build or ins- BUILDING USE
prove for purpose Of sale J. R IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A ESSORSPARCEL 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 conlractons)licensed pursuant to
the Commctori License law. ' SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec.-,B&P.C.fur tills WATER HEATER W/VENT 6.00
Ow"` [)ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COAIP., SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of conxnl to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. RE SPRINK ENERGY T-Pd
0
Z ❑ Certified copy is tiled with the city inspecion division.Applicant MISC.- REFER TO ORD. Y❑ IN[] Y ❑ NF
CC _� PERMIT ISSUANCE 10.00
LU CIiRTIFICAT1iONSATIOTINS FROM WORKERS' FLOOD ZONE A.L.u.C.
W � COMPENSATION INSURANCE PLG.GONER. LIC.NO.
vLG.
CL 0 (This section need not be completed if the Demur is for one TOTAL Y❑ N[_ Y❑ N
hundred dollar,(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O w UJ subject to the Worken'Compensation Laws of California.
CL Uax Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} U3 NOTICE TO APPLICANT: If,atter making this Certificate of Ex-
H = emption,you should become subject to the Workeri Compensation APPLIANCE 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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby aftion 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,0130 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 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 PLUMBING
f ordinances and stale laws relating to building consvuction, and BOILER-CO f(3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to ester upon the BOILER-COMP (0wr 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(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 conmquence of ilia
ranlin�yf th mY MECH.CONT. LIC NO.. MECH.
60 o5. 1 OTAL TOTAL
Signature of Applicant/ rentor Date
OFFICE COPY