2098 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI.- POINT PEN ONLY
PER IT NU /�
BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT (� }(
BUILDING - J �J
X ADDRESS
C f_U E 1' 4BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwN R'S Let, - " .. T„ PLAN CHECK VALIDATION
""'"E 7 /�aELECTRIC PERMITFEE1-1 nda w`'~•sS nil 1 PNDNE ]NCONTRACTORS _ Frov'E GerTLETS-SWITCHES-RECEP 5.00/1.00
NAME � Myof7lleM CO• kX L.C.NO, I HTING FIXTURES 5.00/1.00
CONTRACTORS PPL IANCES-RESIDENTIAL 4.00
ADDRESS 1 SMIfQ S,an AyV4L CQ,
X 1171 A-54151"AV4, PNDNE -G4$ PANELS 5.00 DATE OF APPLICAT ON
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC, 3 OB
LIC,No. SIGNS TRANS.
ARCH.SS ENG. S.00 PERMIT VALIDATION
' AGGRESS SPECIAL CIRCUIT
ZIP rEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
961W v
0 0 Sp
LICENSED CONTRACTORS DECLARATION a
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELELT. PLG. MECH.
H N i. Professions Code.and my license is in full for�c/e and ffe L & ❑ El
o m - License C ss Lic.Numbe -.-LE<T ✓ L U 5
H w Date L Contractor 6
•+ J "BUILDING PERMIT;,
a w u OWNER-BUILDER DECLARATION "-,INFORMATION",pvnuc �^
SLL- I hereby affirm that I am exempt from the contmetor's License MISC.- REFER TO ORD
w0¢ Law for the following reason.(See.7031.5,Businessand Professions PERMIT IS 1 6.00 VALUATION 5/FT.
WNJ Code:Any city or county which requires a permit to construct,after, OOO
¢<G improve,demolish.or repair any structure.prior to its issuance,also ELEC.CONTR. .N0. ELEC. /
y D ar requires the applicant for such permit lO file a signed statement that TOTAL PERMIT TO
W$n he is licensed pursuant to the provisions of the Conlmclor s License _ ;., !� 9
>
Law(Chapter 9(commencingwithSection 7000)ofDivision3ofthe tr ifi 61+a - u i . r• 7�6_70jal 1219
E a: Business and Professions Code)or that he isezem t therefrom and OTY `� +T P.LUMBINOPERMIT rI) Y.- FEE�{
F ¢D p !+ A y-A,�,t °'-i 1 { A3- f vx S.rY• STORIES TYPE CONSTR.
¢ H the basis far the alleged exemption.Any violation of5eclion 7031.5 �T. RS !.+3.+^t-S. . 2
w. by any applicant for a permit subjects the applicant tuaeivilpenally gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.Urv1T5
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who build,or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.06 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 1NC.4 OUTLETS 4.00
menti an not intended or offered for sale.If,however,the budding
or improvement is sold within one year o!completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDINU U54
In
will have the burden of proving that he did not build or im- RES IND CON Pe Omer
prove for purpose oras e.).
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL 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 contraclar(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.06 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofcoment to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). 11
\( Policy N�L4df.V4CtJ1 J��Qnn AutlnsoeAneE C1.
Q ❑ Certified copy is hereby fufnlssed. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified s filed with the city inspection division.
O Applicant Sf6p��' 4uf ,f MISC.• REFER TO ORD. Y ❑ N❑ v ❑ N❑
Fy - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� - CERTIFICATE OF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. u'`'O
1O TOTAL O Y❑ N❑ V❑ N❑
= Z hundred
sellar, need or be completed if the permit is for one
hundred dollars f 51001 pe less.l
U O I certify that h the performance of the work for which this per- QTY.,� MECHANICAL PERMIT FEE -FEE SUMMARY I,'`• -
U.0 mit is issued.I shall not employ any person in any manner so u m
U become subject to the Workers'Compensation Laws of California. 1
0 W
Date-Applicant BUILDING S
ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,aftersubject
making this Certificate u Ex..
emplio n you Should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO lO�DD C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 103]00C.F.M.) 5.00 SEISMIC FEE t '5D
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued IS". MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.P.50 ELECTRIC
I certify that I have read this application and state that the shove VENTILATION FAN (SINGLE) 3.00 OT
information n correct11 agree ID comply with all city and county 000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building contraction. and BOILER-COMP(3 H.P.of 100,
hereby authorize representatives of this City to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. REFER TO ORD.
(We) agree to Save, indemnify and keep harmless the City of MISC.- CONST.TAX
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00
may in any way accrue against said City in consequence of the
granting Of this permitMECH.CO NT. LIC.NO. MECH. r ,
TOTAL TOTAL o^t�°o
Siµnature of Applicant/Cnnvacror Dam
OFFICE COPY