11794 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING /� APPLICATION & PERMIT
ADDRESS Iotga I 1
/V1 IQS 1J1 BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 11794
OwNER's PLAN C14ECK VALIDATION
• " -IL49 OTV. .1 ELECTRIC PERMIT FEE
KvnONE • /
CCONNTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
JrxQ L.C.No LIGHTING FIXTURES 10.00/1.00
f-ONinACSOn 3 L�. PPLIANCES-RESIDENTIAL 4.00
Pd\A00 5 , `-- T17 `
\1 , PRON46-IRC PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS(OVER 200 AMP) 20.06 PLAN CHECK FEE Y.C.No.
OR
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
noonEss ENG' SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
rs
AEE FEE H.
DREss
MOTORS SSC /
SERVICE CHANGE 20.00
w O o LICENSED CONT RACIORS DECLARATION
< U u I Trenchy affirm Ilet I am licensed under provisions of Chapter 9 ISSUANCE DATE
n a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG- MECH.
F o a Professions Cm and ilieense is in full h
Be o n - Licen ass ._Lic.Numb rEl El
r w Datc� � - _ -C'mrtrncror _ _ .
a Y f BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
A o w uINFORMATION
I hereby afltnn that I am exempt from the Contractor's License IMISC.- REFER TO ORD
VALUATION SIFT.
Law for the following reawn.(Sec.7031.5,Business Bnd Professions PERMIT ISSUANCE 10.00
my Code:Any city or county which requires a permit to construct.alter,
le a G o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC,
M
requires the applicant for such permit to file a signed statement[list TOTAL PERMIT TO
E
$ he is licensed pursuant retire provisions of the Contractor's License � /
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 oft he '..r
4 4 o Business and Professions Code)or that he is exempt therefrom and DTV. y sy: PLUMBING PERMIT," FEE Y`�nv,�//
Be 1-g the basis for the alleged exemption.Any violation of Section 7031.5 ' STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00 -
of not more than five hundred dollars(I500).):
❑ 1,as owner of the properly,or my employees.illi wages as BACK FLOW PROTECT.DEVICE 4.00 ace.CROUP qfs.UNITS
their sole compensation,will do the work,and the sl racture is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Lew 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 that such improve-
mansarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 n
or improvement is sold within one year of completion. the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Doer'
❑ I,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cody.The Contractor's License Law does not apply
to an owner of property who builds or irnproves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoAs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License L.W. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.Inr Ibis WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.PATE ACC.FILE NO.
WORKERS'COMPENSAIION DECLARAT ION WATER IREATI GEQUIP. 5.00
1 hereby affirm that 1 have a mrtificate of consent to self insure.
or a certificate of Workers'Compensation Ins nee.or a certified ZONING ENG.SITE NO,
copy ll" [
Policy N •_ _ L-
0 ❑ Certifi d copy is hereby furnished. J
yFtcz FIRE SPRINK ENERGY T 24
Z Z y�' an[ ¢ ��`{{s�B}� ��1 I Ity inspection Jivixiun.
� p A'ppllcanl �� J 1\C{3.[!�l7 MISC.- REFER TO ORD. Y N1:1 v ❑ No
CP-RTIPICA'1'1:OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O ('Phis section need not be Completed if The permit is for one TOTAL ❑ NEI
U O hundred dollars(SI00)or less.)
I certify that in the performance of the work for which this per- QTY: ' MECHANICAL PERMIT' : ' FEE. FEE SUMMARY.
LL H mit is issued,I shall not employ any person in any manner so as to
O become subject to(he Workeri Compensation Laws of California,
0 CL Date Applicant BUILDING
>_ w NOTICE TO APPLICANT: If,afit,making Ibis Cenificalc of fix- ALTER OR ADD TO 5.00
Z anplioo,you should become subject to the Workers'Compensation APPLIANCE 00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT( 4.00
CONS TRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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(his permit is issued ISec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
• I certify that I have read this application.,,it still,that ti"'
VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all oily and county PLUMBING
ordinances and state laws relating To building conMrrelion, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representalives of This city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL qlL
above-mentioned property for inspection purpoxes.
(We) agree to save, indemnify Britt keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in conuquence,of the PERMIT ISSUANCE 10.00 lozc
gr n' • If this permit. I MECH.CONI. UC.NO. MECH.
ig um of APPi<ant/Contmclo T tc
vA�l + TOTAL TOTAL
OFFICE COPY