10845 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BDILDING APPLICATION & PERMIT
ADDRESS {,
' 1 -..,I ING—ELECTRICAL—PLUMBING—MECHANICAL 10845
/: OWNEP'$ Of V` ' PLAN CHECK VALIDATION
"AME OANELS
ELECTRIC PERMIT FEE
KRONE c AAIEINIi Rs 1 TLETS-SWITCHES-RECEP 10.00/1.00
NAME �, II1Erry INS
µ.•1 .NO. HTING FIXTURES 10.00/1.00
ADDRESS ro �" PLIANCES-RESIDENTIAL 4.00
j R�'�u.
r PHDNE IO.00 GATE OF APPLICATION
ARCH1NELS (OVER 200 AMP) .20.00 PLAN CHECK FEE
OP
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.
oo Ess ENG' - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w
09 LICENSED CON TRACTORS DECLARATION
¢u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a z"' (commemm�g wiOl Section 7000)of Uivixion 3 0l B�sirle'�S esfl�
r wQ H a a�/./1 BLDG. ELECT. PLG. MECH.
x Professions Code,and my license is in full fore ec ❑ ❑ ❑
z D m - License C LIc.Namber
4 m r w Date Contractor
¢ , OWNER-BUILDER DECLARATIO BUILDING PERMIT
(c ,,-<a u INFORMATION
I'xa R:n r 1 hereby affirm 0mt I am exempt from the Contractor's License MISC.— REFER TO ORD
H u. of Law for the following reason(Sec.7031.5,Bus(nessand Professions PERMIT ISSUANCE 10.00 VALUATION
Code.Any city or county which requires a permit to construct,alter,
¢ <I improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a¢ requires lire applicant for such permit to file a signed statement that TOTAL
6 W
is LL Ile Is licensed pursuant to the provisions BL the Contractor's License PERMIT TO
rzi Law(Chapter 9(commeocing with Section 7000)of Division 3 oftle �$
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢I$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 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,AR EA,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 SO.PT.FLOOR AREA TOTALACREAGE
himsoll or through his own employees,provided that such improve-
mentsarenotintendedorofferedfor sale,If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden or proving that h - . - . ,
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting wi .
to 11 1:1 ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 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 IEA.) 1 OR
contracts for such projects with a conlractous)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STA ft .O.Od TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,U&P.C.for this WATER HEATER W/VENT ,00
reason
Owner Date WATER SYSTEM
CI ot loupuloff t ACC.DATE ACC.FILE NO.
. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
1 hereby affirm that 1 hove a cerlilicute of consent to s•If-in Ire, ZONING Or a c rtificate of W kkers'Co ' ion I ou ce or C r icd ENG.SITE NO.
i .3f3j1Y,.1. . .)
I P i�o1Jn
0 Cir' co yIs , yfI ni
Z Z ❑ Celli copy,is f d ith cit inspect' n div isi - FIRES PRINK ENERGY T 2A
p Applicant ISC.- REFER TO ORD. �' N� v[] N4
� N CI RTI ICATE OFE iM ION FRO W K:RS• ?ERMIT ISSUANCE 10.00 ( DOD ZONE aL.0 C.
LL COMPENSAT ION INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ ❑ ❑ N❑
2 (This se n need or be completed if the permit is for one TOTAL Y N Y
hundred dollars($100)or less I
0 O I certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT 14' FE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any mannerso as to
0 L) become subject to the Workers'Compensation Laws of California.
IS. Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} W NOTICE TO APPLICANT': If,after making this Certificate of Ex.
F. ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)"CF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING 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
tile 3097erfo Cance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name H EATI NG U N IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinanms and state laws relating to building construction, and 130ILER-COMPI3 H.P.or 100,000 B.T.U.1 6.00
- hereby authorize representatives Of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. 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
y in any way ecme against said City in consequence of the
g ting of is p ijt ECH.CONT. LIC.NO. MECH,
1 TOT, TOTAL
TOTAL
ign to x of c on dor tc )
OFFICE C Py - f/