7116 1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
RDILDING
/DURESS
APPLICATION & PERMIT
/
0361>
Oa Sre.0 L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7116
OWNER'5 PLAN CHECK VALIDATION
'NnmE - OTY. ELECTRIC PERMIT FEE
O �� vHONE
CONTRACTORS UTEETS-SWITCHES-RECEP 5.00/1.00
NA
.OLIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACT GR' APPLIANCES-RESIDENTIAL 4.00
/
ADDRESS
`/x\ _t,0411,0146- PHONE -O PANELS 5.00 GATE OF APPLICATION
ARCHITECTSIGNS 6 DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
• uc.No. SIGNS TRANS. 3.00
ADD ESS ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
nv TEMP,METER OR POLE INS. 15.00
APPLICANTS _ MOTORS . SEE FEE SCR.
ADDRESS
SERVICE CHANGE 10.00
0.0 LICENSED CONTRACTORS DECLARATION
<aE I hereby affirm that I am licensed under provisions of Chapter - ISSUANCE DATE
A. (Commencing with Section 7000)of Division 3 of the Business anti BLDG. ELECT. PLG. MECH.
,_D i Probe szions Code, rid my license ism full Ibreeppnd el'1-c.
P z 02 - License Class- j Lia Number i./17.#14 ❑
Z w Date_ Contmctor�
m s BUILDING PERMIT
m rt w Q OWNER-BUILDER DECLARATION INFORMATION
rs a MISC.- REFER TO ORD
w 3 LL I- 1 hereby al'finn that I am exempt from the Contractor's License VALUATION $/FT.
nH .. oa Law for the following reason.(Sec.703L5.Businessand Prolessiuns PERMIT ISSUANCE 6.00
Code Any city or county which requires a permit to constnmL alteq
,IQ p Q
w Q nnprove,demolish,lir repair any structure,prior to Its Issuance.also ELEELEC.CONTR�' LIC.NO. . ELEC.
tiL
- O LL requires the applicant for Such permit t0 file a signed statement that TOTAL PERMIT TO
s a tamhe is licensed pursuant to tire provisions of the Contractor's License
rzi
Law(Chapter 9(commencing with Section 7000)ofUivision3ofthe L (3�-
- Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate - by any applicant for a permit subjects the applicant bra civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).).
❑ I,:rs owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 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. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP4.00 ` SO.FT.FLOOR AREA TOTAL ACREAGE ,
• himself or through his own employees,provided that such impro - .
merits are not intended or offered for sale.If,however,thebuildinveg GAS:EA.SYSTEM-11NC.4 OUTLETS 4.00
or improvement Is Sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im . .
REB IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business I LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thriven,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant t0
WER-SANITARI�STORM EA.20O11/B.00 TRACT NO. PARCEL NO.
the Ccutmcmr's License Law. SE .
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Owner Dam WATER SYSTEM 4.00 .ACC.DATE ACG FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent.to SET insum,
a certificate of Workers'Compensation Insurad or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
P I ey No. Company 4
�` Crrtitied ropy •cby f he FIRE SPRINK ENERGY T-24
Z LL Certified y is file w't c city inspection division. MISC.- REFER TO ORD.
Q.` A picxnl� Y❑ N❑ Y❑ N❑
fl' N\ CNTIPI' Ii OP FXfiMITION ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE L.U.C.A.
LU 5. COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. L
CL z (This Section need not he completed if the permit is for ane TOTAL �/ / Y❑ N❑ Y❑ N❑
hundmd dollars($100)nr lv,)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issucd,.l shell not employ any person in any manner so as to s,i
U become subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOTICIi 10 APPLICANT: If,after making this Certificate of Ex-
2 enhpton;you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provhslons of the Labor Code, you must forthwith comply with FEE s
U such provisions or this permit shall be deemed revoked t AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
"CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE
l I hereby alloor that there is a construction Icading agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.).', HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
mornhation is correct. I agree to comply with all city and county PLUMBING
•e ordinances and state laws relating to buildingconstruction, and M4
BOILER-CP(3H.P.or10O,000B.T.U.) 4.00
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 no
ee oxs.
ss
(We) agrto save, indenmif at ep harmlethe City or MISC.- REFER TO ORD.
Cupertino against liabilities,j to costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX'
may in any See5ne a n City to consequence of the
gfanli IS O Is pent Y MECH.CONT. LIC.NO. MECH.
TA TOTAL
Signature p cant/ ntrador Date
INSPECTOR COPY s