10229 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
13U LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
� aDILDanc . cgEry S•-tea APPLICATION & PERMIT 10229 0 2 2 n
ADDnrssQQ � J
n D BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S M ' / PLAN CHECK VALIDATION
��NAIaECITy.
�.� pi 1N Yj Gi ELECTRIC PERMIT ,e LFEE
Viso--e PHONE �O �
,rI CONTRACTORS -
NAME �Lw, CAO,-J-T OUTLETS-SWITCHES-RECEP 10.00/1.00
i LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS '3I+
sc'.2-n J-YA G-Aj'i-" Y,RlrvE 100 PANELS 10.00 DATE OF APPLICATION
ARCHITECT",.`q'` I PLAN CHECK FEE P.C.NO.
OR A`,AEJsI2FV PANELS (OVER 200 AMP) 20.00
ENGINEER
UC.NO SIGNS TRANS. 3.00
ARCH.OR ENG, t R IDATION
ADDRESS SPECIAL CIRCUIT 5.00
I rxiry mazimho VALIF CALzIP 51'115 tTEMP. METER OR POLE INS. 20.00 //AA
APPLICANT'$ MOTORS SEE FEE SCH. IvHN 110n1
ADDRESS
SERVICE CHANGE 20.00 City Of cu
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 PertlnO
u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
m a m tcommencing with Section 7000)of Division of the Bus es BLDG. CT. PLG. MECH.
r y z Professions Coda.and my license iz in full fo
O m - License Class Lic.Number ❑
Z
Date Contractor
H
- s BUILDING PERMIT
¢ A ¢ OWNER-BUILDER DECLARATION RATION ,-
A, N
a N I hereby affirm that I am exempt from the Contractor's License MISC. - REFER TO ORD
aoa Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 ///III VAWATION SIFT.
Code:Any city orcounty which requires a permit to construct.alter, I(/
2 Q improve,demolish,or repair any Stnmture,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC. G
D ¢ requires the applicant for such peanut to file a signed statement that TOTAL P IT TO /
t 6N
E.
m u he is licensed pursuant to the provisions of the Contractor's License
,a z < Law(Chapter 9 tcommencing with Section 7000)of Division 3 ofthe r
4 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT - FEES-
It F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
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 dollar,(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce.GROUP REB.UNITS
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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6,00
I ments are not intended or offered for sale.If,however.the building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING E
builder will have the burden of proving that he did not build or im. RES IND CO PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec. 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
contras forsu License
Lwithacontraorl sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
the Contractor's for such
License Law.
❑ 1 am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 6.00
redson
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of Consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
ropy thereof l Sec 3800.Lzb.C.).
Policy No, Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ coy is filed wi jC city inspection division. MISC.- REFER TO ORD.
O Ap licunt I• Y ❑ N❑ Y [:] N[]F y RKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > TIPICATE OF EXEMPTION COMPENSATON INSURANCE OPLG.CONTR. LIC.NO. PLG.
Z r(This section need not be Completed if the permit is for one TOTAL Y C] N❑ Y❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. , " MECHANICAL PERMIT ;FEE:' FEE SUMMARV„N
IL I- mit is issued,I shall nos employ any person in any manner so as to -
O W become subject to the Workers'Compensation Laws of California. '
a DatO Applicant ALTER OR ADO TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex
F ? emption,you should become subject to she Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE s
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the erfo 3097C MICROFILM
ince of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.Or 100,0008.T.U) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(0.,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 agains( liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence Of the PERMIT ISSUANCE 10.00
granting ofthis permit. MECH.CONT. LIC.NO. MECH. '
P
4q � TOTAL TOTAL,o
Signature of ApplicantlContrac(o Da
OFFICE COPY