11588 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
" BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT, ^ 588
ADORESStol e"v i er ue I 8
p( BUILDING -ELECTRICAL-PLUMBING-MECHffFEE
OWNER'S PLAN CHECK VALIDATION
NAM)AA QTY. ELECTRIC PERMIT
PHONE
CONTRACTORS
RAcroRs
-L NAM UTLETS-SWITCHES-RECEP 10.00/1.00
- <
Ko V oh LIC.NO 2-1 LIGHTING FIXTURES 10.00/1.00
CONFITTACTOR'S APPLIANCES-RESIDENTIAL 4.00
AD RESa f [/ �]
r I PHONE AD _2A10 PANELS 10.00 DATE OF APPLICATION
AflcssrtscTPANELS (OVER 200 AMP) 20.00 PLANCNECK FEE P.C.NO.
Ofl
ENGINEER
LIc.Na. SIGNS TRANS. 3.00
Arco.OR ENG. SPECIAL CIRCUIT 5.00
ADDRESS PERMIT VALIDATION
" 7
zIP ITEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. �J
ADDRESS , �C..
SERVICE CHANGE 20.00
woo LIC17NSED CONTRACTORS DECLARATION
< +u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y< vai (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F 7 Professions o 6my license is in full fur fere ❑ ❑ ❑
z o=- Litems ass // cis Number !,
P L H Dote Contractor-
¢ u BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
ao MISC. REFER TO ORD
X ;A. y I hereby affirm that I ant exempt from the Contractor's License _ VALUATION $/FT.
Fuoa Law forthe followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
ce s¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
o
n W m he Is licensed pursuant to the provisions of the Contracto!s License
Fi >
Law(Chapter 9(commencing with Section7000)ofDivision 3 ofthe
¢o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
ce H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; ,. by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
(heir sole compensation,will do the work,and the structure is nol
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 FIXTURES,PER TRAP 5,00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided(hal such improve- GAS-EA.SYSTEM•1 INCA OUTLETS 6.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-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
131,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 properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with acantr.ctor(s)licensed pursuant to SEWER-SANITAR -STORM !L2 t/10.01
TRACT NO. PARCEL NO.
the Contractor's License Law. 0
❑ I am exempt under Sec..,B.&P.C.for this WATER HEATER W ENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIPPAID 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lub.C.). A •I�-.I�, i
Policy No. Company
0 p�Cetti fied top Is he yfar shed. FIRE SPRINK ENERGY T-24
Z Z /CjL Cerli fie y I e If t• city map on division.
MISC.• y n
p pplicant It OI W. V❑ ry❑ V ❑ N❑
Hy PERMIT ISSUANCE 10.00 '- FLooD zoNE A.L.u.c.
LU CE FICCOM E SATION INS FROM WORKERS'
W > COMPENSATION INSURANCE PLG.CONTE. LIC.N0. PLG. '
CL p (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
7 Z hundred dollars IS 100)or less.)
U O I certify(hal in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
CL. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE.TO APPLICANT: If,after making this Certificate of Ex-
F 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00 C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE
1 hereby affirm the( 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.) 6.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4,00 W
information is correct. 1 agree to Comply With all city and county BOILER•COMP(3 H,P.Of 100,0006.T,U.I 6.00 PLUMBING CAD
ordinances and state laws relating to building construction, and
hereby authorize representatives- 's city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection uses.
(We) agree to save, indemnify nd keep rmless the City of MISC.- REFER TO ORD.
Cupertino onagainst liabilities,Jud ants, costs a expenses which pERM1T ISSUANCE 10.00 CONST.TAX
y y y accr agar said City in co rsequence of the
granting s per MECH.CONT. LIC,N0, MECH.
TOTAL TOTAL
INQa[ a PP¢ raor Data
OFFICE COPY