7135 APPLICANT TO FI'LGIN INFORMATION WITHIN RED-LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION - - PERMIT NUMBER
AD - - - • APPLICATION & PERMIT �� ��
ADDRESS REas - "
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL •
DWrvER'S - ��, - - PLAN CHECK VALIDATION
NAME - T ELECTRIC PERMIT FEE
i L NE n
CONTRACTOR'S —/6 OUTLETS-SWITCHES-RECEP 5.00/.1.00
NAME
LIC,ND: 2 �/� LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S ,
x ,ADDRESS G�/jflSY� !� PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICAT ION
ARCHITECT
- SIGNS : 6.00 " PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. - SIGNS TRANS. 3:00
ADDRESS eruct - SPECIAL CIRCUIT • '5.00 PERMIT VALIDATION
EMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE ,10.00 �SI
1 w o o LICENSED CONTRACTORS DECLARATION" _ vT
u U I hereby affirm that I am licensed under provisions of Chapter 9
Z w ISSUANCE DATE
H 4 (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
-0 V Professions Code," d (cense is in full fore3.��p a t� ❑ ❑ ❑
Zo i w o License CI' Lia Number (y �+J-G - -
_ r Dale Contractor �v�s✓�
S, 4 OWNER-BUILDER DECLARATION IIAN24 BUI D GPERMIT
w ° MISC.— - REFER TO ORD INFORMATION
g ,�v, I hereby affirm that 1 anf exempt from the Comracmr's License VALUATION $/FT.
.. 0 4 Law for the following reason.(Sec.7031.5,Business and Professions 0;
r — PERMIT ISSUANCE • 11
improCunjve,
Any miry or county which requirese permit to is issuance,
alter, '
improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR.' LIC.NO. ELEC.
0 E, requires he applicant for such permittofile a signed statement that TOTAL (/��
u W m u _ v V PERMITTO� -
he is licensed pursuant to the provisions of the Contractor's License
HZi
Law Chapter 9(commencingwOh Section 10001 of Division 3 oldie
i o Business and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE
r the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
m '
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.)of not more than five hundred dollars($500).): -.
❑ I,as owner of he property;or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 -
their sole compensation,will do Ile work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business,and ProfessionsDRAINS-FLOOR;ROOF,AREA,COND. 4.00 '
Code;The Contractor's License Law does not apply to an owner of
property who builds or improves hereon,and who does such work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended or offered'for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.), RES IND CON PB Other'INDUSTRIAL WASTE INTER. 20.00 E] El E] El "�
CI 1,as owner of the property,am exclusively contracting with
licensed contractors to construct tire'project ISec.7044,Business LAWN SPRINKLERS-1 INC5 V.B. 5.00 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
corime Tor such projects with a aonlracWAs)licensedpuisuent to
the Contractor's License Law. +. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under sec. ',B.&P.C.for hisomson WATER HEATER W/VENT - 4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1.have•acertilicateof consent to self-insure; ZONING ENG.SITE NO. '
or a certificate of Workers'Compensation Insurance,or a certified"
Policy Noeof(Sec.3SComp N., -Lab.0Company
0 0Certified copy is hereby furnished. FIRE SPRINK ENERGY T.34
Z'Z plI Cerlifie s fi d with' a cit i cYo division. - �
F p cant —' i� MISC.- - REFER TO ORD. Y'E] NEI Y C] N
CCT CERTIFICATE OF EXEMPTION FROM WORKERS' 'PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.D.C.
LU >
COMPESA
ION
CL 13 (This section need not bCcompleted if TINSURANCE hpermit is for onC TOTAL
PLG.CONTR. LIC.NO. ' Y❑ N� Y� N�
CL 13
� Z limcf.d dollars($10()or lesi). - - -
U 0 1 certify that in the performance of the work"for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL, I— mit is issued,I shall not employ any person in any manner so as to
,O W become subject to the Workers'Compensation Laws of California.
y Date - Applicant" BUILDING
} N NO'PICF: TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
F Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of,the Labor Code, you must forthwith comply with FEE
U' such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION'LF-NDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for I 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.1 ' 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 7 --
Leader's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
.� information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state Jaws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter'upon the SOILER-COMP I 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 3.00 CONST.TAX
t may in any way accrue against said City in consequence of the
BE of this permit MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
rgn are o pplicanlIContmetor Date '
OFFICE COPY