3355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - US E BALL POINT PEN ONLY
l�J'� PERM N
BUILDING PROJECT IDENTI FI N gppLICATION & P IT
AL
BUILDING 3 55
ADDREss
i BUILDING-ELECTRICAL-PLUMBING-MECHANIC
.Q.E -
UwNER's p PLAN C g� LIDATION
NAME peyLe w++� QTY. ELECTRIC PERMIT FEE rub
PHONE ,�y []
caNTRACTo s �SSj�'1� UTLETS-SWITCHES-RECEP 5.00/1,00 MAR 3 0 190
NAME
'�- O LIC.No LIGHTING FIXTURES 5.00/1.00 s
CONTR CTOR'5 pf�� PPLIANCES-RESIDENTIAL 4.00
ADDRESS 6 ,Ciiy, of•CUpertinn-
' �Sr11�Ro! /fP �yy D PANELS 5.00 DATBOFAPPLICATION -
ARCHITECT SIGN$ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG, 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 15.00
A!]: Trs MOTORS - SEE FEE SCH.
aoo
SERVICE CHANGE
o ¢.z T/
r o o L Still CONTRACTORS DECLARATION
S, v u 1 hereby rm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Hz w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH:
to
y i' Professions irjCo nd my license is in full fore : yJfu�t -
z tow- License CI s 4 Lie,Number b �. ❑ ❑ ❑
9 w Uate. Colnrac[arCj6�
w
5 ¢w¢ OWNER-BUILDER DECLARATION P WORMATIONPERMIT
�BLNG
o d U MISC.- REFER TO ORD ----
w3 e_w I hereby afOrm that I am exempt from the Contractor's License VALUATION $/FT.
FU0 < Law for the followingreusun.(See.7031.5,Businessand Professions PERMIT ISSUANCE .6.00 [q i. 1L��
Code:Any city or county which requiresu permit,n colrslrucL aIle,. Vi. `--QP
u
improve,demolish,or repair any slmctm<.pilar to its issuance,also ELEC.CONTR. ELEC.
requires the applicant for such permit to file a signed statement that TOTAL P,.E{RMIT TO
he is licensed pursuant to the provisions of the Contractor's License ifY O Ael aun'_ Odh'
rzQ
Law(Chapter 9(commencingwith Section 7000)of Division Sof the
f M C Business and Professions Code)or,hat he is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ ,he basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CON$TR.
A. by any applicant for a permit subjects the applicant to a 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 emPloypes 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 as owner of
property who builds Or improves thereon,and who does such work FIXTURES-PER TRAP '4.00 SOFT.FLOORAREA TOTAL ACREAGE
. himself through his awn employees,Provided time such improve-
m<n(sare re not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-I1NC.40UTLETS 4.00
Or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDwG USE .
builder will have the burden of proving that he dist not build or int- RES IND CON Pe Done,
prove for purpose of sale.). INDUSTR IAL WASTE INTER. 20.00
[1I,as owner of the property,um exclusively contracting with El 1:3 ❑ 1:1 11licensed 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
,o an owner of property who builds or improves theMon.nild who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projectswith a cmurucmrfs)licensed pursuant In
the Contractor's License Law.-
SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. -PARCEL No.
❑ lam exempt under Sec. .B.&RC.for this WATER HEATER W/VENT 4,00
on
Dale Owner. WATER SYSTEM 4.00 •ACC.DATE ACC,FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
• I hereby affirm that I have a certificate Of consent bI self-insure, ZONING ENG.SITE NO,
car a certificate of Workery'.(4n peasation Insurance.o a certified
copy, erect
Sy�)8(1BIL�.L' U#VQ
Polic LA] r��(mpuny -
Q rl and py is hereby oshed. FIRE BPRINK ENERGYT24
z ❑ Cer,if co II DI t mly inspection division. Y ❑ N❑ Y ❑ N❑
Applican 1 MISC.- REFER TO ORD.
fr CIiRTIFICA 1°IiXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
.LU COMPENSATION INSURANCE PLG.CONTR. uC.NO. PLG.
G- O 1'This u;ction need not.be co rupleted If the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars($100)or less.)
U O I certify',hal in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mil is issued,1 shall not employ any person in any nm nner sm as to
O w
bee omo subject tothe Workers'Compeasulion Lows of California. BUILDING
Dare Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making,his Certificate of Iix- -
F Z emption,you should become subject to the WOrkefs'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of ,he Labor Code, you mus, forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.1 3.00
CONS"fRUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M:)'5.00 SEISMIC FEE.
1 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.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
l 'enit'y that''lave 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 BOILER-COMP(3 or 100000 BTU) 400 PLUMBING ,
ordinances and state laws relating to building construction, and H.P. , . . . .
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, costs and expenses whichCONST.TAX
aigs
may in any way acerae t said City in consequence of the PERMIT ISSUANCE 3.00
gran' g of this per f ^^^ MECH.CONT. LIC.NO. MECH.
p�G S VY TOTAL TOTAL
Signature plic [IContrac,or Date
OFFICE COPY