09582 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS a19e8tON71 Drive- APPLICATION & PERMIT 09582
A 535 BUILDING'-'ELECTRICAL-PLUMBING-MECHANICAL
"
OWNER'S - PLAN CHECK VALIDATION
NSa1 Al eri - 2 80 2 DTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10,00/1.00
Was; ating LIC.NO. C20 465 6 LIGHTING FIXTURES 10.00/1.00
NTRAAOTOR's
ADDRESS
a PPLIANCES-RESIDENTIAL 4.00
CO
155 Commercial Stree PHONE739iii;0516 PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECKFEEP.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDDDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 N10
'ASS SEE
ADDRESS MOTORS FEE SCH. DEC
DDREEA
SERVICE CHANGE 20.00
7
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Cf d.'��le
<u w I hereby uffrn that I am licensed under provisions of Chapter 9 b 95$(/q E 3'
X y <N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. MECH.
F D z Professions Code license license is in full fo pt.
zo z m w Liccnsc Class Li Lic.Number�O -
Q m J Date Cont
actor
-
-12f31/8r Atlas-He g
E cr w a. OWNER-BUILDER DECLARATION BUILDING PERMIT
U INFORMATION
W ;°A r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u o J Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALugTION $/FT,
Code:Any city or county which requires a permit to construct,alter,
aa o improve,demolish,or repair any structure,prior to its isssmnce,also ELEC.CONTR. LIC.NO. ELEC.
A w-DLL requires the applicant for such permit to file a signed statement than TOTAL PE MIT TO
m a- he is licensed pursuant to the Provisions of the Contractor's License
r z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
F• $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES" TYPE CONSTR.
by any appllcanPlor u permit subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(45000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to all 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-
mentsarenotintcadedOroffered for sale.If,luowever,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner•
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with0 C1 0 El
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'file Contractor's License Law dues not apply
to an owner olfproperty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) .1.00
contracts for such projects with a contractons)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACTNO. PARCEL NO.
❑ lam exempt under Sec..,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner _ Date WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 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
LScLB'7p4,R�yp7U Allied Paeif
Policy No.- tY1��I1]1I1YY U . „
O Certified copy is hereby furnished. FIRE SPRINK' •ENERGV TZ4
Z Z Certi fmd��cppppyY is ftI�'wi}`�hh the city inspection division.
FO Applicant__aS1a8_ fiaTeil� MISC.- REFER TO ORD. Y[3 N❑ 'Y E] NC3
cc CERTIFICATEOP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL COMPENSATION INSURANCE PLG,CONTR. I.C.NO. PLG. -
CL Z (This section need not be completed if the permit is for one TOTAL V N� Y Q PSN❑
hundred dollars(5100)or IcssJ ,
U O• 1 certify that in rite performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY .-
LL U mil is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
.. y Date Applicant- BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
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 per...it shall be deemed revoked - AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.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 workdor which this permit is issued ISeb. MICROFILM
3097,CY.C.1. HEATING UNIT(TO 100,000 B.T:U.) 8.00 8.00
Lender's
Lender's Name Name HEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC
'
Prettify that I have read Ibis application and state That Inclabove VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
r� ordinances and state laws relating to buildingconstruction.and BOILER•COMP13 H.P.Gr 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter union the BOILER-COMP Over 10 ,000 )SEE FEE SCH. _ MECHANICAL,
above-mentioned property for inspection purposes. _
(We) agree t0 save, indemnify all(] keep larmesa the City of MI - " ER TO ORD.
Cupertino against liabilities,judgments, Lysis and equences which P I SUANC 10.00 0.00 CONST.TAX
m ' any way accrue against Said City in consequence of One '
gl�gwcffot
g his permit. MECH.CONT. LIC.NO. MECH.
/.Z3�''� /�� TOTAL TOTAL
X-� c fu/ : �0 18 00
' Applicant/Con ractor Date - '
OFFICE COPY •_. _ "