4562 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
I '
BUILDING PROJECT I DENT]FICATI ON PERMIT NUMBER
I BaILOING APPLICATION & PERMIT
�w2 ADDRESS �{� , e 4562
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
�,L NAME PLAN CHECK VALIDATION
O OTY. ELECTRIC PERMIT FEE
aNE
CONTfl ACTORS
rvnmE OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00 '
ADDRESSTDRs _ APPLIANCES-RESIDENTIAL 4.00
. I
PHONE PANELS. 5.00 DATOF APPLICATION
OR
CHITELT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION.
ADDRESS, SPECIAL CIRCUIT 5.00
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
'02 LICENSED CONTRACTORS DECLARATION
a u I hereby affirm that I um licensed under provisions of Chapter 9 �}-
(commencin ('(] fuels I O 63 ANCE DATE
< y g with Section]0001 Of Division 3 of the Business and (� BL G. CT. PLG. MECH.
F RA
m i Professions Code;andlny license is in full force and effect. ❑ ❑
o0m p License Class Lia Number
r m R J Date Contractor
no II,
TSE a OWNER- 'BUILDINGPERMIT
_ 0 m D BUILDER DECLARATIONINFORMATION
w ;u w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u o v, Law for the following reason.(Sec.7031.5,Busiuessand Professions - $/FT.
fNi Code:Any city or county which requireso permit toconstruct,alter, PERMIT ISSUANCE 6.00
rt = a 00 improve,demolish,or repair any structure,prior to its Issuance,also FLED.GONTR! LIC.N0. oC O
ELEC.
carol
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
zaLaw(Chapter 9(commencingwith Section 7000)of-Division 3af0e
f i c Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
or f m the basis for the alleged exemption.Any violation oSection 7031.5 P-F CO NSTR.
by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.)
of not more than fila hundred dollars($5001.): -
❑ I,as owner of the property,or myemployees with wages as BACK FLOW PROTECT. DEVICE
their sole compensation,will.do the work,and the structure is not 2.00 OCC.GR u RES.UNITS �
intended or offered for sale (Sea. 7044}.Business and Professions 4 /G / f /.aYJ
Code:The Contractor's License Law does notupply to an owner of DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 02 ;rV
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such improve-
mentsarenotintended or offered for sale.If,however,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or ire- GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BUILDING USE.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00RES IND N o
❑ as owner of the property, exclusively conlrncting with
licensedd contractors to construct the
❑ ❑ ❑ ❑
project ISec.]044,Business LAWN SPRINKLERS- 1 INC 5 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
contracts for such projects with a contractors)licensed pursuant to
the Contracmr's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exemptutder Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00
X
Date Ow ne WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 4.00
1hereby affirm that I have a certificate Of consent to self-insure,
or a certificate Of Workers'Compensation Insurance,or it certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company _
0 ❑ Certified copy is hereby famished FIRE SPRINK ENERGV.T24
2 Z ❑ Certified ropy is filed with the city Inspection division.
F O Applicant MISC.- REFER TO ORD. y ❑ - N❑ Y Q N�
Ir W CERTIFICATEOP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSAT'ION INSURANCE PLC.CONTR. LIC.NO. PLG.
Z) (This section need nut be completed if the permit is for one TOTAL y❑ N[Jv 0 N❑
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per, GTV. 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 Workers'Compeasatlon Laws of California. G
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING ..30
T w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the 1Workers'Cam APPLIANCE 4.00 PLAN CHECK- provisions of the Labor Code, you must forthwith comply uwilll,
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE �f"a
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I 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 laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives ins of this city to enter upon rite 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 CONST.TAX
may in any way accrue against said City in Consequence Of the PERMIT ISSUANCE 3,00
ntin Of ennit. MECH.CONT. LIC.NO. MECH. Ora
TOTAL TOTAL
Ignatpre ofA licant/Contractor Dom ••
OFFICE COPY