10156 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATI . PERMITNUMBER
ADIL[71NG- _ APPLICATION & PER q O q
Do`Ea//,3D Go r.J �rP I I
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 56
PLAN CHECK VALIDATION
. N CITY. ELECTRIC PERMIT FEE
or PHDN S d0
NRMER aR's OUTLETS-SWITCHES-RECEP 10.00/1.0000ro
G I"I L' LIc.NoS�� ? LIGHTING FIXTURES 10.00/1.00 ai9
CONTRACTOR'S
ADDRESS o/9tlf'✓¢- �' APPLIANCES-RESIDENTIAL 4.00 d' /T
a PHONE P PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P,L.N0,
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCH,ORENG. PERMIT VALIDATION
ADDRESS - SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
aoDREss ..��// ,'- MOTORS SEE FEE SCH, P
D �S/Pdf
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARA ION TEMP.POLE 30,00
a u w 1 hereby affirm that I am licensed under provisions of-Chapter!)
4 y (commencing with Section 7000)of Division 3 ofthe Business and ISSUANCE DATEBLDG. ELECT. PLG. MECH.
r w i Professions Code rid y ice rise is in full for ( - ❑ O ❑
Z 0 m- - License CI: Lia Number
O u F w Uutc Contractor �1�r` gt (��`l
4 y E J 4 P G p
I ¢ ¢ w a OWNER-BUILDER DECLARATION BUILDING PERMIT p. .
s o s ° INFORMATION;, '
w ; w I hereby attain that I am exempt from the Contractor's License MISC.- REFER TO ORD
a. o 4 Law for the following reason.(Sec.703 1.5,Business and Professions VALUATION $/FT.
- JPERMIT ISSUANC 10.00
Code: e,de city or cor my which structure.
u tune permit to consuanc ,aeq
- tt ¢ ¢ improve,demolish,or repair any Mructure,prior to its issuance,also ELEC.CONTR. LIC.N0. /
a %m¢ requires the applicant for Such permit m file a signed statement that TOTAL
he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
FZQLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe d �)s�
14 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT ,FEE Le-+/ I
it s- $ the basis for the alleged exemption.Any violation of Section 7031.5 ' STORIES TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER IEA.) 5.00
❑ I,as owner the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
(S
inter sole compensation,will the work,and the structure is not
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA,) 2.00
builder will have the burden of proving that h - .e did not build or im- BUILDING USE
prove for purpose of sale.). IN DUSTRIAL WASTE INTER. 3000 RES IND CON PS Other
❑ L as owner of the property,am exclusively contracting with , El El El El El
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 VB6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B.
t0 an Owner of property who builds Or Improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
❑ lam exempt under Sec..,B&P.C.for this WATER HEATER W/VENT 6.00 '
reason
Owner Uate WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK F,RS'COMPENSA'I']ON DECLARATION WATER TREATING EQUIP, 5,00
I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby t ...ished.
Z 2 �( Certlll d : h ed w' h the city inspection division. '
O A{hplicunt �{ � P"/'C� MISC.- REFER TO ORD. FIRE SPR INK ENERGY T.24v [3 NE] v ❑ N[D
CI: N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
IL 0 ('Phis section need not be eonhplovil it'the permit is for one TOTAL v[:] N v ❑ N❑
LD 2 hundred dollars 15100)or less)
U O 1 Certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mil is issued,I shall not employ any person in any manner so as to
O 0become subject to the Workers'Compensation Laws of California.
Ed Q. Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NO'T'ICE "f0 APPLICANT: If,after making this Certificate of Cx-
)..- Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor U Code, you most forthwith comply with FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C,F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCC.F.M.) 6.00 SEISMIC FEE
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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address - HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC Obi.
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances
n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
information
and state laws relating to building construction, and
hereby authorize representatives for ins of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
to authored property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabi' es, ndgmchhts, Cosls 'nd expenses which CONST.TAX
may in any way ac ue a Anst Said 6ty i consequence of the _ PERMIT ISSUANCE '10.00
grantin of ispgh MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL pd
Signal 'of Applicant/Contractor Xate
#.-OS- „ n hr - a *L
OFFICE COPY ,per_