3134 j�LICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI_ POINT PEN ONLY /41
E,BU I LDING PROJECT I DENTIFICATI ON PFR TN aR
> A°°Ra BUILawc'APPcTRAcA�ONL&'PERMIT 31 ^1n
RwLowc I J 'Y
" 31/ Ofr1J .ate � - - MBING—MECHANICAL `
Ov NER'S - _ _� PLAN CHECK VALIDATION
l� NAME
^ I/ ,��� !s
CONTRACTORS I - CITY ELECTRIC PERMIT FEE
` GNE ao
'
NAME yy jUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00 -
CONTRACTOR'S
ADDRESS �s - APPLIANCES RESIDENTIAL 4.00 i
t: PHON — PANELS 5.00 DATE OF APPLICATION
ARCHITECT ,PLAN CHECK FEE PC.NO.
DR SIGNS - 6.00 , n^y
ENGINEER
AENG. Lm.NO. SIGNS TRANS. 3.00
ADDRESS OREss SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP. EMP.METER OR POLE INS. 15.00
ADDRESS rs MOTORS - SEE FEE SCH.
APPLICA
SERVICE CHANGE 10.00 PAID
in or i
r00 LICENSED CONTRACTORS DECLARATION,
a i w 1 hereby affirm that I am licensed under provisions of Chapter 9' 1r�� ♦651TANCE oAJJTE
as ¢��sppp ''' (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. -PLG. MECH.
0 y�,/ Professions Cod a 'y license is in full for P�d ff d ❑
oi o License Clasy Liu.Number y y 1
M F Date! Contmc[or
x BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
X ;u m I hereby affirm that I am exempt frori.the Contractor's License MISC.— REFER TO ORD
H u O J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
vgwgTlON $/FT.
Ew03 Code,Any city or county which requires a permit mconstrucl,after,
OU
Q � ¢ 2improve,demolish,or repair any structure,prior to its issuance, ELEC.CONTR, LIG NO. ELEC. i /
0 IC requires the applicanLfor Such permit to file a signed statement that TOTAL PERMIT TO
a w mhe is licensed pursuant m the provisions of the Contractor's License
Fza Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc ?.4-rt, Cd ✓t'�
x 0 Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
X t- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n3 � by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).)'.
❑ 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,EA,CON D. 4.00 A)—/
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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve-
mentsare net intended oroffered for sale.If,howeveq the busldingL GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS.-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON 'Pfl Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 EJ ElEl � �j
CI 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 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'Pursuanf to SEWER-SANITARY-STORM EA.200ft/6.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.-for this z/
WATER HEATER W/VENT 4,00 0? ( '
anon
Date Owner WATER SYSTEM727
4.00 ACC.DATE ACC.FILE N0,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have u certificme of consent to self-Insure,
or a certificate of Workers Compensation Insurance,or a certified - ZONING_ ENG.SITE NO,
copy thereof(Sec.3800,LAC I
Policy No,—Company../.s. �� STJ)p�led
/
❑ Certified copy Is herebyrfu niche
Z 2 ❑ C24
ertified copy Filed 11 the city i ec ' ivmc FIRE SPR`INK� ENERGY LN
� O Applicar, z MISC.- REFER TO ORD: YCoe � 'A1 YE
CC CERTIFICATE OF FXF,MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE
LU COMPENSATION INSURANCE PLG.CONTH. LIC.NO. pLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y E] N af.e--ry�
hundred dollars(5100)or less.
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- 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. BUILDING / 00
y
Date—Applicant ALTER OR ADD TO MECH. 4.00 .
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex
F Z emptian,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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE J�
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,Civ.C) - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UN IT.(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county r 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 of this city to enter upon the 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,'cosle and expenses which PERMIT ISSUANCE 3.00 YCONST.TAX
may in any wa accrue against said y In cons qo ce of the
grant acprit J MECH.CONT. LIC.NG. MECH.
Irl y lj� TOTAL Q
-nature Of Applicant/Contractor me TOTAL 3/
OFFICE COPY