3091 / APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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APPLICATION & PERMIT3091
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL PLAN CHECK VALIDATION
CITY• ELECTRIC PERMIT FEE
�/� UTLETS-SWITCHES-RECEP 5.00/1.00
J c. G. r 26 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS /JV/L APPLIANCES-RESIDENTIAL 4.00
70 PUONE PANELS 6.00 DATE OF APPLICATION
ORRCmT" SIGNS 6.00 PLAN CHECK FEE P.L.NO.
ENGINEER
' LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00 1 -
APPLICANT'S
ADDRESS MOTORS SKNUCH.
SERVICE CHANGE
woo LICENSED CONTRACTORS DECLARATION AN 24 Y
Fi W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y i Professions Cod124LER-BLD1
a in full for at t(e�L I o upertm h1
Oi m o License Clausic.Number'" (_� ❑ Q ❑ ❑
F m 0 j Date ommmor
a x f J - BUILDING PERMIT
E a R DECLARATION
0 o u INFORMATION
w ; u w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
1 O¢ Law for the following reason.(Sec 7031.5,Business and Professions VALUATION S/FT.
� - g PERMIT ISSUANCE 6.00
Code:Any city or county which requims a permit to construct,alter,
s ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. (/s
G u requires the applicant for such permit to file a signed statement that TOTAL -/ PERMIT TO
Z
2 he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter9(commencing with Section 7000)of Division 3 ofthe
Z O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
2H � the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(85001.):
❑ 1,as 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 docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,Provided that such improve-
mems are not intended 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-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im . . .
RES IND CON PB Omer
.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nal apply
to owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OV ER 5IEA.) 1.00
contracts 1'or such projects with a contractor(s)liecowd pursumrt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC FILE NO.
WORK ERS'COMPENSA1'ION DECLARATION _ WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificateofemor t to sell'-insure, ZONING ENG.SITE NO.
of a cflicrexate of Workers'Compensation ln�s'u�r�+nc- . ;e certifi
copy therfilrue f 35rk Workers'
LabCS�
Policy No. CompunY V
O 9�Certifted copy is hereby furnish d. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified c fty 's led ith Hie 'ity inspection division.
MISC.- REFER TO ORD,
P:O Applicant-� v ❑ N❑ Y ❑ N❑
�'�, PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
X CERT IC "f OP EXE11PT'ION FROM ORKERS'
LU IPIiNSATION INSURANCE PLG.CONTR. LIC.NO, PLG. V❑ N❑ Y ❑ NE]
Z 1' nus section need not he completed if the permit is in,one TOTAL -
hundred dollars(S 100)or Icss.)
U O I certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, 1 0.11 not employ any person a any munner sa as to
O W become subject to the Workers'Compensation Laws of California.
n Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE.TO APPLICANT': If,after making this Certificate of Ex
H ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCT DON LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perlormmnce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50 �D
Lender's Address ELECTRIC
I certify that l have read this application andoal,that the above VENTI LATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building congmation, and BOILER-ODMPI3 H.P.or 100,0008.T.U.) 4.00
hereby aulhori/e representatives of this city to enter upon ih° 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 Ju ments, costs and expenses which CONST.TAX
may in any•way accrue uI 1 sai�dly in conuquence of the PERMIT ISSUANCE 3.00
granting of er i1. MECIA.CONT. LIG NO. MECH.
TOTAL TOTAL
S natur A licanl/ ontmetor Date
OFFICE COPY