2889 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION PERMITAU
BUILDING APPLICATION & PERMIT 000
v aDDRE55
BUILDING_ELECTRICAL-PLUMBING-MECHANICAL o J
OWNER'S -- - - PLAN CHECK VALIDATION
T NAME OTY. ELECTRIC PERMIT FEE
ONE
CONTRACTORS.
N 'p OUTLETS-SWITCHES-RECEP 5.00/1.00
NG III
ILIGHTING FIXTURES 5.00/1.00
,� CONTRACTOR 1,116 JAPPLIANCES-RESIDENTIAL 4.00
/ �W�L CJfiKJ PHONE) a/-SM PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AARCH.OR
DDRESS ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
- zlv TEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS '
�tl/FtE SERVICE CHANGE 10.00 - //
o o LICENSED CONTRACTORS DECLARATION X/ l8 6
a U,U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H 2 (emGman.cciinng wall Scam.70. 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y z Professions C.
/ ' se is full for '
Z o y- License C ass_ Lic.Numb E3 El E13
r Date Conhacto
a x E BUILDING PERMIT
5 ¢ ¢ OWNER-BUILDER DECLARATION
t. o a-" MISC.- REFER TO ORD INFORMATION
X 3 s- I hereby affirm Thal I am exempt from the Consand is License
F u. 0 st Low for the following reason, 703L5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city 01 county which requires a permil to construcl,alter, g j/.�
Q p ¢Q Inlpin Ve,demolish,or repair any S1Netllre,prior to its issuance,JISn ELEC.CONTR. LIC.N0. ELEC. PAU
- DLL requires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
w $a he is licensed pursuant to the provisions of the Contractor's License
FZ > La.,(Chapter 9(commencing with Section 7000)of Division 3 ofthe n (1/Qj �M�LCja2,f
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FE12 vv ��..
¢ H O the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES TYPE CONSTR.
n ;$ by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollarsf4500L): Cit of Cupertino
❑ I,as owner of the property,or my employees with wages as BACK F LOW 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 Professiolss - 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 does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. mems are not hrough
ownempld forSle.If,ho ever,hat the
improve- GAS-EA.SVSTEM-1 4,00
mems are not intended or offered for sale If, mpleveD the building
or improvement is sob 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 ht did not bulb or IIn' RES IND. CON PS Orhe,
prove for purpose of sale)' INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,he exclusively comm,,Bu with ❑ ❑ ❑ ❑ ❑
licensed colons Cors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's s License Law does not apply
to contracts
owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 _the
Contractor's
ctor's h projects with a contr'vctor(s)licensed pursuant to
the Comrumor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl lam exempt under Sec, .B.SP.G.for ode WATER HEATER W/VENT 4.00
eason
Date Owner WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP', 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof 3800,Lab.C.I
Policy No. Comp ny_!�B/L/.OL4C.9ti�6
Q ❑ Cttlilied py is he yluuu//�(({yyy```sj��s��j�-J FIRE SPRINK ENERGY T$4
Z Z �Cer" is cd •i iry inspection vision,
O Alfplica MISC.- REFER TO ORD. v ❑ N❑ v ❑ rv❑
~ m_ PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 L.U.C.
cc CERTIFICATE OF EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC,NO, PLG.
0_ 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y.❑ N❑
D Z hundred dollars(S 100)or less.)'
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner seas to
Ubecome subject to the Workers'Compensation Laws of California. f�
O Of Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING �3JT<
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK -
provisions of file Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C,F.M.) 3.00 FEE �J
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lauding agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
i rdina ncis n correct I agree to comply with all city and rouand PLUMBING
ordinances and state laws relating t0 building construction, and BOILER-COMP(3 H.P.Or 100,0008.T.U.1 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mcnlioned property for inspection purposes.
(We agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperl a against I' it ides,judgments, casts and expenses which - CONST.TAX
may any way c a sr City in consequence of the PERMIT ISSUANCE 3.00 -
g this le / � CH.CONT. LIC,NO. MECH.
p,/13�6Y ME '°'"` TOTAL 37 S
Signature of Applicant/COnhactor Dale
OFFICE COPY