11826 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY A A
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11826
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S v - PLAN CHECK VALIDATION
NAME r
AdslmTY. ELECTRIC PERMIT FEE
V� V 15 DNE / /V'JI✓'
CONTRACTORS
E OUTLETS-SWITCHES-RECEP 10.00/1.00
/Z oWA ) LIC.NO. LIGHTING FIXTURES 10.00/1,00
NTRACTO PPLIANCES-RESIDENTIAL 4.00
ADDRESS �^r �I
Nn6 PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ErvG. - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00 O
APPLICANT'S MOTORS SEE FEE SCH. /I
ADDRESS
SERVICE CHANGE 20.00
CorO LICENSED COM'RACfORS DECLARATION
<u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE'
v~i< , BLDG,(commencing with Section 70001 of Division 3 of the Business and ELECT. PLG. MECH.
Professions Code,and my license Is in full force and effect.
zo* License Class Lia Number-
0r El El 1:1 ❑
z r O flats Contractor �� SEP l u
a , BUILDING PERMIT
IY ¢ ¢ OWNF'R-BUILDER DECLARATION
rz w " MISC.- R F R INFORMATION
K
3 LL s- I hereby affirm that I am exempt from the Contractor's License ( Q„��{7,
u O¢ Law for the following reason.(Sec.7031.5,Rusinessand Professions pERM1T ISSUANCE 10.00 VALUATION $/FT.
� - 0 Code:Any city or county which requimsa permit to construct,alter,
2 ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG.
O Be requires the applicant for such permit to file a signed statement that TOTAL Lao
X 8 ]or is licensed pursuant to the provisions of the Contractors License PERMIT TO
rz>m Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe TOLY/o �6,6e
¢ box ness and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ = the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dnllars($500).):
0 I,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
Cade: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.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsole.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is Sold within one year of completion,the owner
GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 Baa DING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 30.00 - RES IND CON PB Other
❑ 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:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects will,a contractors)licensed purstmnt to
the Contractor's License Law. 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 Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
ar a certificate of Workers'Compensation Insurance,or a cerlified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 2
Z-2 ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
CC T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLI > COMPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL v❑ N❑ Y ❑ N❑
hundred dollars($100)or less) Ed
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
OW become subject to the Workeri Compensation Laws of California.
y Daly Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT': If,after making this Certificate of Ex-
♦- 2 enlption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, YOU must forthwith cons Ply 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 - AIR HANDLING UNIT(OVER 10,000QEM.) 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G UN IT(OV ER 100,000 B.T.U.)9.50 Q
Lender's Address ELECTRIC
. I certify that 1 have read(his application and slate that the ubove VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws Gaining to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BAILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
ubovrmontione property for inspection put ores.
(We) agree save, in an a harmless the City of MISC.- REFER TO ORD.
Cupertino aga' t liabilities,judgmen s, o s and expenses which CONST.TAX
may in y ay accrue agujnst sai consequence of the PERMIT ISSUANCE 10.00
gra an permit /!7 H.CONT. LIC.NO. MECH.
y /a TOTAL TOTAL
Signature o Appli /Contractor Date
OFFICE COPY ,