14804 APPLICANT TO FILL IN INFORMATION WITHIN.RED'UNES _ USE BALL POINT PEN ONLY
B@11LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT, :'� �" `. A
PbDIN -.. 14 8 0 4 .
/Q, UILDING - ELECTfl(CAL-PLUMBING-MECHANICAL T VV
DWrvER'S - '4 PLAN CHECK VALIDATION
CITY: ELECTRIC PERMIT FEE '
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LJCaVT PHONE ZO 1769
CONTRACTORS UTLETS-SWITCHES-
RECEP 10.00/1.00
NAME �,�pS�
I, '�V `YY�•�I//Llc.rvO�3 Z- LIGHTING FIXTURES ' 10.00/1.00
CONTRACTOR' <<��J C. - PPLIANCES-RESIDENTIAL 4,00
r AO REss /�y[
' 5 PHONE 713 + PANELS 10.00 DATE OF APPLICATION
ARCHITET PANELS (OVER 200 AMP( - 20.00 - PLAN CHECK FEE - P.C.NO.
OR
ENGINEER '
' sec.NO. SIGNS'TRANS.� ' 3.00 •.
ARCH.OR ENG. $PEOIAL OIROIIIT 5100 „ PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 - '- --'
APPLICANTS MOTORS SEE FEE SCH.ADDR -
'ESS- SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION
u 1 hereby affirm that I am licensed under provisions of Chapter 9 • - ' ISSUANCE DATE
y¢ N (commencing with Section 7000)of Division 3 of the Business and _84DO7 ELECT. ' PLG. ,MECH.
0 y z Professions A and my license is in full for -a - ❑ '❑ ❑
z O y- ProfeLicenssions
CI' se is
0 m H Date Contractor _ -
a u f r BUILDING PERMIT
2 w OWNER-BUILDER DECLARATION - INFORMATION _
w ; u y I herebyaffirm that I am exempt from the Contractor's License MISC.- - REFER TO ORD
P VALUATION $/FT.-
Hw. O0 Law fertile following reason,(Sec.7031.5,Business and Professions - PERMIT ISSUANCE - 10.00
in Code Any city or county which requires u permit to construct,alter, 1137-S
Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - - - LIC:N0. ELEC.
iL o urequires the applicant for such permit le file a signed statement that TOTAL PERMIT I U ,
w-m y he is licensed pursuant to the provisions of the Contractor's License
Hz > Law(Chapter9(commencing with Section 7000)of Division 3 of the - -
' zz a Business and Professions Code)or that lie is exempt Oterefrom andDTV. PLUMBING PERMIT FEE'
F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES -TYPE.CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
iv
0 I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not - - .
imended.or'offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,_AREA,COND. 5.00 -
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 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve - - -',-
mentsarenotintendedorofferedforsale.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS' 6,00 ,
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4.1EA.) 2.00 - BUILDING USE
builder will have the burden of proving that he did not build or im- - RES 'HND CON PBOther
prove for purpose of saled. - - INDUSTRIAL WASTEdNTER.. :30.00
❑ L 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. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner ofproperty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) ..1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAN ITAfl Y-STORM EA.200ft110.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Ism exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00 •
reason
Owner - - - Date WATER SYSTEM 5.00 'ACC.DATE_ Ace.FILE No.
WORKE.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 _
;l 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 -
f,DQ copy thereof(Sec.3800,Lab.C.).�, I.
r .,
- Policy No. Company
O ❑ Certified ' yesI ",by,fu isIT FIRESPRINK ENERGY T34.
Z Z A❑ Certifie o y is filed lh cit inspection division. MISC. - REFER TO ORD. y ❑ N❑ y;O' N❑
P Of" PPlicanf . . '
2_N - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE, 10.00 FLOOD ZONE . . A.L.U.C.
LU >_ .COMPENSATION INSURANCE PLG.CONTR. UIC.INO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL - Y❑ N❑ y,,❑ N❑
D Z hundred dollars IS 100)or less.)
00
1 certify that in'the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE _ FEE SUMMARY ..
U_ F mif is issued,1 shall not employ any person in any manner so as to
U become Subject to the Workers'Compensation Laws of California. BUILDING g S�
to Date � Applicant - ALTER OR ADD TO MECH. 5.00
�. rail NOTICE. TO APPLICANT:,IE after making this Certificate of Ex-
F ? emptier,you should become subject to the Workers'Compensation. APPLIANCE _ 5.00 PLAN CHECK
rovisions of the Labor Code, you must forthwith comply will, FEE - / raj
P �-
CJ such provisions or this permit shall be deemed revoked. AIR'HANDLING UNIT(TO 10,OOD C.F.M.) 4.00 e
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE S7D
I hereby affirm that there is a construction lending agency for. EXHAUST HOOD (WITH DUCT). 5.00
the performance of the work for which this"permit is issued(Seca' - MICROFILM,`
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name I. HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC-
Lender's Address -
I certify that 1 have read this application and stale that the above VENTILATION FAN,(SINGLE) 4.00
information Is correct I agree t0 comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws elating to building construction, and -
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over l00,000BTU)SEE FEE SCH. MECHANICAL
above-meritloned property for inspection purposes.' - _
(We) agreetosave, Indemnify and keep harmless the City of MISC:- „-; •REFER TO ORD.
Cupertino against liabilities,Judgments,-costs-and expenses which CONST.TAX'
'• may i y way accrue against said City in consequence of the 'PERMIT ISSUANCE 10,00
ran f this perm Y y�� MECH.CONT. -LIC.NO. MECH.
TOTAL', TOTAL
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goal
re licant/Contractor Date"
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OFFICE COPY