11970 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -, USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
�( Va,,, n,NG APPLICATION & PERMIT
a0DRES F BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11970
OWNER'S4 PLAN CHECK VALIDATION
\^/ PMEt ^ wA /'��._ 1 [y QTY. ELECTRIC PERMIT FEE
S PV_tJc PHONED I _
N xER"° s UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No b 77 LIGHTING FIXTURES 10.00/1.00
coNrmacroR' - APPLIANCES-RESIDENTIAL 4.00
"'PHONE ^�[JfV PANELS 10.00 DATE OF APPLICATION '
ORCHRECTR K PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER -
UC.No. SIGNS TRANS. 3,00
AARCH.OR OORESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH. 9
SERVICE CHANGE ' 20.00
o o LICENSED CONTRACTORS DECLARATION 'pw-eR - !/
a i w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Q a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H 0 i Professions CoY@ ce se is in full f e,gpdF ct. ❑• ❑ ❑
z O= License lass iL Lic.Number -
0Date Contractor
Y E - BUILDING PERMIT
w u OWNER-BUILDER DECLARATION INFORMATION
w
; a w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION §/FT.
�+ 0 Q Law for the following reason.(Sec.7031.5,Businessand Pm@sroms PERMIT ISSUANCE 10.00
Code:Anycily orcounty which requires a permit to construct,alter, -
Q O improve,demolish,or repair any stratum,prior r0 its issuance;also ELEC.CONTH. LIC.NO. ELEC.
0 w requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractors License
riQ
Law(Chapter 9(commencing with Section 7000)otTivision3ofthe
Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
5 _ $ the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
•❑ 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
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 '
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. GAS•EA.SVSTEM-11NC.40UTLETS 6.00
memts are not 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.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWNSPRINKLERS-1 INC 5 V.B. 6.00 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EAg200ft/10.00
(1"� TRACT NO. PARCEL NO.,
the Contractor's License Law.
re❑mlamexemptunder Sec. ,B.&P.C.forthis WATER HEATER W/VEN .pc"• 400
Owner - - Date WATER SYSTEM ri N149 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING E¢UI_P. ,5r0
I hereby uffirm that I have a certificate ofeoment to self'nsure• r ZONING
or a certificate of Workers'Compensation Insu ce,or rtified D\QY ENG.SITE NO.
copy the S_ Q 19 � ,Ns \.
Policy N
0 ❑ Celli fled copy is he Eby furnished. FIRE SPR INK ENERGY T 24
❑ Certifird cow-is Agile=rwi� the city, inspection division. MISC.- REFER TO ORD. y N Y N
H p Applicant lli ,�,�_ ❑ ❑ ❑ ❑
cc CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
Ill COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, a
ILO (This section need not be completed if the permit is for one TOTAL C,211 Y[]. N❑ Y ❑ N❑
D 2 hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL - mit is issued,I shall not employ any person in any manner so as W
U became Subject to the Workers'Compensation Laws of California. 11
0. Date Applicant ALTER OR ADD TO MECH. 5.00 FBUILDING '
} m NOTIC17 TO APPLICANT: If,after making this Certificate of Ex-
F ? emptioa,you should become subject to the Workers'Compensation APPLIANCE 5.00 provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=12.F.M.) 6.00 1 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(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 3097,Cie.C.).Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address
I certify that l hascmad this application andslme that the above VENTILATION FAN (SINGLE) 4,011 sti
information is correct. I agree to comply with all city and county PLUMBING d `�
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise 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 which' CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gra�j(Ing of his per t. MECH.CONT, LIC.NO. MECH. TOTAL
-r \ r�...�L.lr({f/� Q�,►.{�\�-y-1 TOTAL
SIgIsT•a/ture pphcan Contractor Dute `
OFFICE COPY