4209 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-'1 BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
suit DING - APPLICATION & PERMIT 4209� 4 G J
ADDRESS
Q/O!- �,� � �•G � BUILDING -ELECTRICAL-PLUMBING-MECHANICAL nO(t'f
ca NER'sDD r - PLAN CHECK VALIDATION
II N E OTV. ELECTRIC PERMIT FEE
- u_S-r PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00er
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 .
- L ADDRESS �) r1.�J y.-J
J 3 �y PHONE [�/L / PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER '
LIC.Not SIGNS TRANS. 3.00
ARCH.OR
ENG.
A - SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS - MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
°OF'O 2 LICENSED CONTRACTORS DECLARATION �•�l�S
IS U U I hereby affirm that I am been sed under provisions of Ch apt cr 9 ISSUANCE DATE
y a H (Commencing with Section 7000)of Division 3 0(the Business and BLDG. ELECT. PILO. MFCH.
N Professions Code and my license is in full force and effect. ❑ ❑ ❑
z O m icense Class Lic.Number
4 m r w Is a Contractor
¢ m s BUILDING PERMIT
¢ ¢ w 4 OWNER-BUILDER DECLARATION INFORMATION
vt ;LL m I hereby affirm that I am exempt from the Contractor s License MISC.- REFER TO ORD VALUATION S/FT.
Hu Oa Law for the following reason.(Sec.10315,Businessand Professions PERMIT ISSUANCE 6.00
Code',Any city or county which requires a permit to construct,alter,
¢u,Q Q improve,demolish,or repair any structure,prior to itissuance,also ELEC.CONTR. LIC.NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
HIi Late(Chapter9(commencing with Section 7000)ofDivision 3 ofthe �rL
f 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation Of Section 7031.5 STORIES TYPE CONSTR.
d ; _ by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER IEA.14.00
of not more than five hundred dollars(5500).1:
❑ 1,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 - S0.FT.FLOOR AREA TOTAL ACREAGE .
meats are not
ownemployees,for sale.
if,ed that however,
the
improve- GAS-EA.SYSTEM-I 4.00
mems are not ugh his
or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im' ,RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ - ❑
licensed contractors to-construct the project(Sec.7044, Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with'a contmctons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl I am exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate ofconsent 10 self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.)Roys4ot,tw� '
Policy No. Company
❑ Certi�f�ieEBd copy ishereby l moished. FIRESPRINK ENERGY T.24
Ce
- Appplicam rill copy c cit copy is films wiD inspection division. SC.- REFER TO_ORD. Y ❑ No Y ❑ N
❑
Z `� MI
cc CERRTII F ICATE O F EX IiMPTION F ROM WO R K E RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
' > COMPENSATION INSURANCE PLG.CONTH. LIC'.NO. PLG.
a O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
=)'Z hundred dollarslSIDO)or less.)
U O 1 certify that in the performance of Bre work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL G mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation'Laws of Caldorni..
0 y Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workeri 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=C.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 HEATING UNIT (TO 100,000 B.T.U.) '4.00 MICROFILM
3097,Cn.C.).
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Ainformation is correct. I agree to comply with all city and county -COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating m building construction, and BOILER
hereby authorize'representatives of this city to cater 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 Imnnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
in n any way accrue against said City in consequence of the
Ip
n ng of[his permit i/ MECH.CONT. LIC.NO. MECH. '
Iry ' ��31�tf3 TOTAL TOTAL
a re of Applicant/Com actor Uate _
' - OFFICE COPY