3732 ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P NAN LY
BUILDING PROJECT IDENTI FICATION - ' - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
3 7 3 2
ADDR 5
i
Zpp BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
_-__
O NEP' - PLAN CHECK VALIDATION
WW" QTY. ELECTRIC PERMIT FEE
. PHONE
CCONNTTRRAACTOR's UTLETS-SWITCHES-,RECEP 5.00/1.00
�,J` LIC.No. ' LIGHTING FIXTURES 5.00/1.00
i ADDRESS OR's -r -- -PPLIANCES-RESIDENTIAL 4.00
AD/OR•E�s�s �(eD QILt�N✓IOIJT
14;7 / 4a PHONE (� I9 PANELS , 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE Pc.. yo
OR a�fC N
ENGINEER
' LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PE MIT V LIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS.' 15.003
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
q
SERVICE CHANGE 10.00
,02 LICENSED CONTRACTORS DECLARATION J� ,n0
C,U I hereby affirm that I am licensed under provisions of Chapter 9 I
Q y (commencing with Section 7000)of Division 3 of the Business andBLDG. PLG. MECH.
H D i Professions Code,and my license is in full force and effect ❑ ❑ 1:1z 0 2 License Class—Class Lic.Number
z D Dale Contractor
xi BUILDING PERMIT
X a w a OWNER-BUILDER DECLARATION INFORMATION
" MISC.— REFER TO ORD
Z
g LL y 1 hereby affirm Olal I am exempt from the Contractor' License VALUATHDNM $/FT.
HLL0 J Law for the following reason(Sec.703 L5,Businessand Processions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
6 ¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIQ NO. ELEC.
n La D LL requires the applicant for such permit to file a signed statement
PER that TOTAL PERMIT TO
La m relie is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapter 9(commenciog with Section 7000)of Division 3 of lite'
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ce H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant loacivil penally
Of not more than five hundred dollars the .): ALTER-DRAIN&VENT-WATER (EA.) 4,00 / 3�n•\
C1 I,as owner of the property,or my employees 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 an owner of
Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.IT,FLOOR AREA TOTAL ACREAGE
- , himself re through his own employees,Provided eve such improve- � .�'•
mems are throuot gh his or offered employees,
or provided that r.such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
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 im RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 �/
❑ 1,as owner of the property,am exclusively contracting with L7 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASS ESS ORS PARCEL rho.
and Professions Code:The Contractor's License Law does not apply n/
to an owner of property who tracts 'sor improves Thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 V7
contracts for such projects with a contractmos)licensed pursuant to
the Contractor's License-Luw, SEWER-SANITARY-STORM'EA.200ft/8.00 TRACT NO. PARCEL NO.
. ❑ Tum exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 /�
reason
Date owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, - - 2 NING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3A00,Lab.C.I
Policy Company
O Certified is here yfurnih FIRE SPRINK ENERGY T 2`4'
Certified gyp f pith tl it 'i sp cY division. MISC.- REFER 70 ORD. t.][f
Z O Applicant—_C Y❑ Y ❑
Fy PERMIT ISSUANCE 6.00 FLOOD ZONELU Awef
Q: — CERTIFICCOMPEN EXEMPTION INSURA M WORKERS'
>_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. .�s.�..�
CL Q (This section need not be completed if the permit is for one TOTAL ,Y❑ ' LJNL j
:3 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work I'or which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L.. ? emption,you should become subject to lite Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.15.00 SEISMIC FEE �U
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.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon life 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 aga a said 'ty in conse9ue ce of the PERMIT ISSUANCE 3.00
glomi hasp mit MECH.CONT. LIC-NO. MUCH. D
1d TOTAL TOTAL
Sign atu cof Applicant/Contractor DtgF �L "�-
OFFICE COPY