5750 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION'& PERMIT
DRE
,BUILDING—ELECTRICAL—PLUMBING-MECHANICAL - 5750
.• OWNER's - PLAN CHECK VALIDATION
N4
/IIlO � OTY. ELECTRIC PERMIT FEE
V .� 1..NE
.CONTRACTOR'S
NA a a39660 OUTLETS-SWITCHES-RECEP 5.00/1.00
C Ic.NO. LIGHTING FIXTURES 5.00/1.00
nooT ess To s _ q O - PPLIANCES-RESIDENTIAL 4:00
Y O y t
.NE:7.21 OI , PANELS 5.00 GATE OF APPLICATION
OgCH1iECT SIGNS 1 . 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER -
' SIGNS TRANS. 3.00 '
AARCH.OR DDRESS ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER'OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS � Y
SERVICE CHANGE• 10.00
wo o -LICENSED CONTRACTORS DECLARATION
a o La I hereby affirm that 1 am licensed under provisions of Chapter 9 - IS
SU DATE
E-a i (commencing with Section 7000)of Division 3 of the Business and
a BL ELECT. PL❑G. MECH.
r m i Professions Cod n license Is in full f ire
o z m o Lice nic,"as m.Number -
Date.,J f�ontmc[o
a Y BUILDING PERMIT a`
¢o re 4 a O OWNER-BUILDER DECLARATION + INFORMATION'
it ; r I hereby affirm that 1 am exempt from the Contractor's License MISC.,-- REFER TO ORD
m u U.o so Law for the following mason.(Sec.7031.5,Business and Professiods VALUATION S/FT.
— g PERMIT ISSUANCE B,BO ,
Code:Any city or county which requires a permit to construct,alter,
QQ Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. _
a w mquires the applicant for such permit to file a signed statement that TOTAL rER O
he is licensed pursuant to the provisions of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the
i Qo Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢}-m the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TVP ONSTR.
i ; ,. byany applicant fora permit subjects the applicant toa civil penalty ALTER-DRAIN (EA.) 4.00
of nol mom than five hundred dollars(5500).): - i+
❑' 1,as owner of the property,or my employees'ivith wages as BACK FLOW PROTECT.DEVICE 2.00 OC GROUP. S.U
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 Con oefor's License Law does not apply to an owner of
e property who builds or improves thereon,and who does such work _ FIXTURES-PER TRAP 4.00 sD. L EA TOTAL ACREAGE
' rc himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC;40UTLETS 4.00
menti anot intended or offered for sale.If,however,the building
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 ice-
prove for purpose ofsale.). IND CON PB Other
❑ '1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑, ❑ ❑ • ❑
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 Corsuch'projects with a contraclof(s)licensed pursuant to - -
theContractor'sLicenseLaw. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ Ince exempt under Sec. ,B.&P.C.for this ---7
WATER HEATER W/VENT '4:00 '
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACO.FILE N0.
WORKBRS'COMPENSATION DECLARATION WATER TREATING,EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insum, - ZONING ENG.SITE NO.
or a.certificate of Workers'Compensation.insurance,or a certified
copy thereof f Sec 3800,Lab.C.).
Policy No. Company
` 0 ❑ Certified copy is horehy m h ' FIRE SPRINK ENERGY T29
'❑ Certi ' c y f♦t wi e on Elm MISC.-, 'REFER TO ORD.
Z O Applicant • - V❑ N❑ Y ❑ N❑
~ as PERMIT ISSUANCE 6.00
fY — CER IEICCOI OF COMPENSATION
FROM WORKERS' FLOOD ZONE A.LU.C.
^`W >' COMPfiNSATION INSURANCfi PLG.cONTR. .. LIC.N0.. PLG,
1 O (This section need nut be Completed if the permit is for one - TOTAL ❑ N❑ V❑ Is'[]
0 Z hundred dollars IS 100)or less.)
U O`. .-.I certify that in the performance of the work for which Ibis per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
U. H mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws oC Californi0. ar.w1
Date Applicant BUILDING So
0. ALTER OR ADD TO MECH. 4.00
} ED NOTICE.TO APPLICANT: If,after making this Cerfificate of Ex.
.F, Z ensptlon,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 10AWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
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.f HEATING UNIT(TO 100,000 B.T.U.) • 4.00
Lender's Name
Lender' - - HEATI NG UN IT(OVER 100,000 B.T.U.)7.50' ELECTRIC
s Address
NNI certRy.that I have read this application and state that the above VENTILATION FAN (SINGLE). _ 3.00
fonna0or Is correct.I agree to comply with all city and county -PLUMBING
oMmances and state laws 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 BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes. n,•
(We) agree to saveindemnify keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judg ts, costs and expenses which PERMIT ISSUANCE 3,00 CONST.TAX -
may in any way a crue ns i Cit in c agree of the
Syr
O pe ul MECH.CONT. - LIC.NO. MECH.
TOTAL
7.G TOTAL
o ignatureof Applican onl etor Dac
OFFICE COPY - ,.