11358 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTI FICA PERMITNUMBER ,
'BUILDING APPLICATION & PER 11358
ADDRESS
lu� I 'I BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
wNER'S PLAN CHECK VALIDATION
. NAME m QTY. ELECTRIC PERMIT FEE
`C�OONN"TRACTOR'"s r� C� O I OUTLETS-SWITCHES-RECEP 10.00/1.00 L
V 1 !� /LYCJJO IGHTING FIXTURES 10.00/1.00 ?:
CONTRACTORS •?Ll,��- PPLIANCES-RESIDENTIAL 4.00
A R 5 7 A
l'{J a - E PANELS /O 1U.D6 (/ PATE OF APPLICATION
ARCNITEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS J'\
IV SERVICE CHANGE 20.00 �r
Doo LICENSIiU CONTRACTORS DECLARATION s
a u I hereby affirm that 1 am licensed under Provisions of Chapter 9 ISSUANCE DATE
waw (commencing with Section 7000)of Division 3 of the Business and {' O'Tr BLDG. ELECT. PLG. MECH.
r w z Professions Coyd�,, an license is in full fare nd of ec r ❑ ❑
2 O m- License loss C--` Lic.Nuin .,�
@ w H D Dare - ��Contractor_ ! '
Qys � 1 c 1
¢¢ OWNER-BUILDER DECLARATION QI{If1O BUILDING PERMIT
a w v INFORMATION
Da. MISC.- EFER TO ORD
X ;0 v4i I hereby affirm that I so exempt from the Contractor's License
F u w ¢ Law for the fallowing reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00 vnLunnON $/FT.
Code:Any city or county which requires a permit to coastrucL alter, ...�
2 x ¢G improve,demolish,or repair any structure,prior to its issuance,also EL C GDNTR, LIC. U. ELEC. C 7 Bp
n wDLL requires the applicant for such permit to file a signed statement that TOTAL V PERMIT TO
$w he is licensed pursuant to the provisions of the Contractor's License I E[.c e7
> Law(Chapter 9(commencin with Section 7000)of Division 3 ofthe
f i o Business and Professions Code)or that he is exempt therefrom and QTY-F__
TY- ' _ PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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,AREA,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 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30,00 RES IND CON PB Done,
❑ 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 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 n eonlmetood licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.PATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure, ZONING . ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy that (Sec. C.).
Policy No-&se I' Y CcI' Lin
O Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z 2 CaHifie W t9 fl�d with it, .t�',Lgsp�C.(ion(:!Msion. MISC.- REFER TO ORD. -
O Apphant�1__17.1_IS-Or-�(_C_L�f.(C.f-�..- Y❑ N❑ Y ❑ N❑
~ rn t _ PERMIT ISSUANCE 10.00
Lu - CIiRTIFICATEPE IiATION INS PROMWORKERS' FLOOD ZONE A.L.u.C.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
:) 2 hundred dollars IS 100)or less.) -
U O I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
0. ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you tilos[ forthwith comply with FEE
U
such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.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 s ork for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.1B.50
Lender's Address ELECTRIC 3 I
I certify that[have read this app kation and stme tlmt the above VENTILATION FAN (SINGLE) 4.00
information is correct I agree toTomply with all city and county PLUMBING
ordinances and state laws relating 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 BOILER-COMP (Diver 100,000BTU)SEE FEE SCI-. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
1.3y in any way accrue against said City in consequence of the
gr tingof permit. I MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL
$1 store of A A
hCanl/Contraelor -5.
• OFFICE COPY