8489 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS ^ A n
2QI119 919Z' / BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Ul )./1v,)
OWNER'S
NAME 1 PLAN CHECK VALIDATION
• QTY. ELECTRIC PERMIT FEE
/ IG PRONE T
CONTRACTOR'S pp ww�
/ NAME 1 C.3� UTLETS-SWITCHES-RECEP 10.00/1.00 SMID
G / 11 IC.NO. LIGHTING FIXTURES 10.00/1.00 'APR 2
C,ONTRACTOR'S
ADDRESS �'gmybe// PPLIANCES-RESIDENTIAL 4.00 9 198 '
vNOrvE PANELS .10.00 ATE FAPPLI TION
ORCI Ec PANELS (OVER 200 AMP) ' 20.00 PL .c.No.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRRESS END. v SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ��'�
APPLICANT,
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
_02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H Z H IComwa
rtieneing ll Section 7000)of Division 3 of the Business and SLOG. ELECT. PL MECH.
F N z Professions Code,an my license is in full force a of ❑ ❑ ❑
Z 0 m - Liecnsc Class Lic.Number -? T�Z
9 y ic Uatc.K,f�' Contractor L.^s'. Z DI L
, 2 j r.
¢_ C w a OWNER-BUILDER DECLARATION BUILDING PERMIT
`� ;u n- I hereby WE....that I am exempt Croat the Contractor s License
MISC.- REFER TO ORD INFORMATION
F LL o J Law 101 the Ibllowing reason.(Sec.7031.5,Business and Pmfesslons PERMIT ISSUANCE VALUATION S/FT.
Code:Any city oT County which requires a permit to construct,alter, 10.00
re ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ca
- n tc require.,the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m w he is licensed pursuant to the provisions of the Contractor's License
Fz > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is excerpt therefrom and OTY. PLUMBING PERMIT FEE
art r 0 the basis for the alleged exemption.An violation of5ection 7031.5
o g p Y STORIES TY CONSTR.
a ;°' by any applicant fora permit subjects 5500).licannoucivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of no,more than five hundred dollars(my employees
❑ Las owner at theon,property,or my.and tires with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sale compensation,will do the work,and the s(nccture 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 FTfµ,OOR AREA TOTAL ACREAGE -
himself re through his own employees,provided that such improve- -
Oroup,renoentis old or within
yearsale,l L Imovevur,the building GAS-EA.SYSTEM-11NC.40UTL'E 6.
or lder vemrnt is sob within one year of cunt pletiun,leo owner.
m-
huilder will have 166 burden of proving thw he diA mol hnild or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of suleJ' INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ 0 El 0 -
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and 1'mossions Code:The Contractor's License Law docs 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 a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.20 / 0 TRACT NO. PARCEL NO.
❑ lam exempt under See ,B.&I'.C.for this. WATER HEATER W/VENT _
reason
Owner Date WATER SYSTEM I
44Ace.DATE L, ACC.FILE NO.
WOR K ERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm ilia, 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(Sec.3800,I.ab.C.).
Policy No./.1. 30k.mpaiy fQy„a
O {} Cer11�L opY ,herebyh-red. FIRE SPRINK ENERGY T24
Z Z f3 Cgtil • ops is ed with the city inspection division.
♦- O/ IApplirant � MISC.- REFER TO ORD. v N� Y ❑ NF]
M Ln CI:RTI PICATE 0171 XEMI"IION FROM WORK Ii RS' PERMIT ISSUANCE j10 FLOOD ZONE A.L.U.C.
LL > CO$IPENSATION INSURANCE PLG.CONTR. C.NO. 'PLG.
CL Z 1 '1'eis section need not be completed if the permit is for one TOTAL Y❑ NE] Y [3N❑
hundred dollars($100)or Iesx)
V O 1 certify the, in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workeri Compensation Laws of California.
n Date Applicant BUILDING
} m NOTICI7'f0 APPLICANT: If,after making,his Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F 2 emption,you should become subject to tine Workers.'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of,the Labor Code, you must forthwith comply with FEE
CJ such provisions I or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hcrchy idt irm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's dd. HEATING UNIT(OVER 100,000 B.T.U.)9.50
lender's AAdress ELECTRIC
I certify that l have read this application and sone that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city unJ 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 mentioned
representatives this city es enter upon the BOILER-COMP (Over,100,000 BTU)SEE FEE SCH. MECHANICAL
hereby anlionad propetly for inspection or this
purposes.
(We) agree to save, indemnify and keep harmless 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 consequence of tint PERMIT ISSUANCE 10.00
granling/n this ermit. MECH.CONT. LIC.NO. MECH.
Gf - TOTAL
• TOTAL /
Signa, re of Applica tContraclor Dat
INSPECTOR COPY
I