0606 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL_ POINT PE771606
BU I LOING PROJECT I DENTIFICATI ON
wr BD DING APPLICATION & PERMIT' w
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O NF S PLAN CHECK VALIDATION
NAME ^ OTY. ELECTRIC PERMIT FEE
u0ry
coMEE csoa
NAQ OUTLETS-SWITCHES-RECEP 5.00/1.00
r LIC NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS jr pPLIANCES-RESIDENTIAL 4.00 '
�TfJ
r PHONE, 3A0 PANELS 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS B QQ
ENPLAN CHECK FEE P.C.NO.
OR
GINEER
uc.NO, ISIGNS TRANS. 3.00
ARCH,OR FNG. SPECIAL CIRCUIT 500 PERMIT VALIDATION
AhoRFss .
ZiF TEMP.METER OR POLE INS. 15.00
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS
SERVICE CHANGE 10.00 p
ZLICENSED CONTRACTORS DECLARATION
¢ U I hereby affirm that I am licensed'under provisions of Chapter9 ISSUANCE DATE
¢ 2 w
(commencing with Section 7000)of Division 3 of the Business and BLDG., ELECT, PLG. MECH.
G w i Professions Cade,and my license is in full fort ary eTact.
® ❑
as o w - License las Lie.Number
9 r Daley Cs Confracwr
a y 2� ./ ;� BUILDING PERMIT
5 Ic w ¢ OWNER-BUILDER DECLARATION INFORMATION
o e. ° 'MISC.- REFER TO ORD
X ;LL N I hereby aD'irm that I am exempt from the Contrudois Limnsc VALUATION SIFT.
L
u o ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 .�
Code:Any city or county which requims a permit to construct,alter,
Q 5 Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR.. LID,N0. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL / JPMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License X,, PERMIT
IT
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the rCM
¢ Business and Professions Code)or that he is exempt therefrom andDTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.$ 1 STORIES TYPE CONSTR.
i3 � by any applicant for a permit subjects the applicant(us civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK K9W 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 DRAIN R,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 docs such work FIX ES PhTRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS. .S STE NC:4 OUTLETS 4.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA. STEM- 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build of im- RES . IND CON PB Other
prove for purpose of sale.). IND IAL IN ER. 20.00
0 I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
Incensed contractors to cont«ct the project(Sec.7044,Business LAWN KLER -1 INC 5 V.B. 5.00 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 SPR NKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200fT/6.00 TRACT NO. PARCELING.
O I am exempt under Sec.-,BAP C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 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 certilIicd
copy thereof(Sec.3800,Lab.C.)f
Policy No. Company
Q ' ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified ca y is led withh rise amity inspection division.
P: MISC.- REFER TO ORD.
U Applicant Y ❑ N❑ Y ❑ No
+n
LU CERTIFICATE OF EXEMPTION TIFROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
'
LU > COMPENSATION INSURANCE PLG.CONTR. LIQ NO. PLG.
1 O (This section need not be completed if the permit is for one TOTAL �d Y❑ N❑ Y ❑ N❑
D Z hundred dollars(51 OD)or less.)
U O 1 certify that in the performance of the work for which this Per- OTY.. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner w as to
U become subject to the Workers'Compensation Laws of California. '
0 w Date - ApPlicam BUILDING e7 7-/xv
d ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE r�r Zp!
t..1 such Provisions or this permit shalt be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.F.M.) 5.00 SEISMIC FEE A(�3
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 ITO 100,000 B.T.U.) 4.00 MICROFILM ..
3097,Civ.C.). pp
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC �/r
Lender's Address
I certify that I 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 010-0
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 4.00
hereby authorize 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 o!the PERMIT ISSUANCE 3.00
granting of this pe MECH.CONT. LIC.NO, MECH. Q/
/ TOTAL TOTAL'
Signature of Applicant Contras or
�' OFFICE COPY