4421 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT, PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS APPLICATION & PERMIT f� 1
aooREss n LI I
R BUILDING-ELECTRICAL-PLUMBING -MECHANI
4 En' - AN CH ECKVAL IDATION
x "° E f TY ELECTRIC ELECTRIC PERMIT FEE
PHONE
Co"T ` " OUTLETS-SWITCHES-RECEP 5.00/1.00
x' LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTH Rs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS 6.OD11 PLAN CHECK FEE P.C.NO.
on
ENGINEER
LIC.NO. SIGNSTRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL'CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT MOTORS SEE FEE SCH.
SERVICE CHANGE - 10.00 10103Qr�
'02 o LICENSED CONTRACTORS DECLARATION -
a v W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a Q (commencing with Section 7000)of Division 3 of the Business and LOG. ELECT. PLO. MECH.
r O Professions Code,and my license is in full force and effect. C 0%d Z' ❑ ❑ ❑ ❑
z o u°i License ClassLie.Number
O z Fw Dale Contractor
s BUILDING PERMIT
w Ft OWNER-BUILDER DECLARATION INFORMATION
E
0. 1' 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
3Y P QQ�qkLUATION $/FT.
F u 0 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 '+lv
Code:Any cityor county which requires a permit to constrict, J ;!40
Q ¢ 4 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G u requires the applicant for such permit to file a signed statement that TOTAL OCT ERMIT TO
a w m w he is licensed pursuanttothe provisions of the Contractor's License '
' Fz) Law(Chapter 9(commencing with Section 7000)of Division 3 of the 01`
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT F E
IS r $ the basis for the alleged exemption.Any violation of Sect ion 7031.5 T ONSTR.
A. by any applicant for permit subjects the applicant toacivilpmuddy , ALTER-DRAIN&VENT-WATER (EA.) 4.00 tTf//Pyb
of not more than fisc hundred dollars(8500).):
Cl I,as owner of the property,or my employees with wages as - BACK FLOW PROTECT. DEVICE 2.00 c P RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered far sale (Sc,. 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 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mends are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM'-I INC.4 OUTLETS 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 net build or int- RES IND CON PB Oma,
prove for purpose of sale.). I INDUSTRIAL WASTE INTER. - 20.00
❑ 1,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. 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 SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conrractod s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam m
5reptu der Sec. B,&P.C.list this WATER HEATER W/VENT 4.00
reason /C.
Dale .Cl- - 3 as/y 6T-E JJ' WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPF:N3 TION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a'certificate of consent to self-insure, ZONING ENG,SITE NO.
v or a certificate oCWorkers'Compensation Insurance,.or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No.No. Company
Q ❑ Certifiedcopyisherebyfurnished. FIRE SPRINK ENERGY L24,
Z �/ ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O� Applicant Y❑ N❑ Y ❑ N❑
Xy CERT'IFICAT,OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
QJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLC.
CL O (This section need not be completed if the permit is for one TOTAL Y E] N❑ Y F] N❑,
=) Z hundred dollars($100)or less.)
U O I 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 so as to
V become subject to the Worken,Compensation Laws of California.
so Date Applicant BUILDING (�� J�
a ALTER OR ADD TO MECH. 4.00 / T
} a NOTICE TO APPLICANT: IF,after making this Certificate of fix-
F ? 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE Ufa
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(Sea HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.),
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that(lie above VENTILATION FAN (SINGLE) 3.00
information is correct, 1 agree to comply with all city unit county PLUMBING
ordinances and state laws relating to building constructionand BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
jure by authorize representatives of this city to enter upon; the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL
•
above-mention perry for inspection purposes. _
(We) agr to s e, i e and keep harmless the City of misc., - REFER TO ORD.
Cupertino ' uinst iia bf' ,jail en costs and expenses which CONST.TAX
may in y a a s ' fly in consequence of the PERMIT ISSUANCE 3.00
grand fl is f MECH.CONT. LIC.NO. MECH.
- _ �b�' TOTAL TOTAL /e,,
Si atureo pp' ant/Contracto Date
OFFICE COPY