7073 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aUILOING APPLICATION & PERMIT - g�O n
ADDRESS r r
tV�. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME
OTkV,�a ,4 ELECTRIC PERMIT t ` FEE ? '
CO TRACTORS
NAME ; UTLETS-SWITCHES-.RECEP 5.00/100
LIC.No. -LIGHTING FIXTURES 5.00/1,00
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL - 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CNECK FEE P.C.NO.
OR 'M SIGNS
ENGINEEy/1a..+-+� y�Q� SIGNS TRANS. 3.00 '
�r LIC.NO
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
AOOfl E55 `
ZIP TEMP.METER OR POLE INS. 15.00 •fes
APPLICANT/y� .� S MOTORS SEE FEE SCH.
ADDRESS I�0
e• t„ .� SERVICE CHANGE t(yyy� 10.00
wo O LICIiNSED CONTRACTORS DECLARATION 'lIJ
•air 1- 1 hereby affirm That I am licensed under provisions of Chapter 9 ISSUANCE DATE
Nay (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. 1 A 13 I• 1� ❑ ❑ ❑ ❑
z O w- License Class_Lic.Number J I s`• - -
9 w r Dote Contractor
`5 Y IF it 'OWNER-BUILDER DECLARATION Plisl of fUOBf�)�0 BUIL'DINO PERMIT
a la O MISC.- "REFER TO ORD ' ' :F'IN f§R.
w;a- n I hereby affirm That 1 am exempt from the Contractor's License
LL04 Law fertile followingmaspn.(Sec.7031.5,Businessdnd Professions PERMIT ISSUANCE VnLOATwN
� -0 Code.Anycity orcounly which requiresa permit to construct,alter,
¢ rc Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signet statement that t TOTAL PERMIT TO'
a. w$ he is licensed pursuant to the provisions of the Contractor's License T q
Fit Law(Chapter 9(commene ing with Section 7000)o f Division 3 of the
'4 Business and Professions Code)or that he is exempt therefrom and OTY:.' '+PLUMBING PERMIT FEE'
at 1- the basis for the alleged exemption.Any violation of Section 7031.5 z. STORIES TYPE CONSTR.
d ; - by any applicant forapermit subjects the upplicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollar,($5000.):
❑ 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 gO,FT.FLOOR AREA TOTALAC REAGE
himself or through his own employees,provided Hour such improve-
ments arc not intended or offered forsale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 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 vB Dl
rev or purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
1��yfp�I,as owner Of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
Bl�nsed contractors to Construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS FAHCEL ND.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exam t under S B.&1'.C.far this WATER HEATER W/VENT 4.00
OwOw on
ne ate WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKF:RS'COMPENSATION DECLARATION - WATER TREATING EQUIP, 4.00
I hereby afOnn that I have a certificate of consent to self-insure. ZONING ENG,SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy therenf(Sec.3800,Lab C.). -
Policy No. Company
Q" ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 ❑. Certified copy is filed with the city inspection division. MISC.-- REFER,TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
CC LO CERTIFICA,rh OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > I COMPIiNSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
1 Q (phis section need not be completed if The permit is for One - TOTAL Y❑ N❑ Y❑ No
U Z hundred dollars(S 100)or less.) ,,,g��� �-� ` - - '
U-O I certify that in the Performance of the work for which this per l h''MECHANICAI:-PERMIT.s " IEEE '' ;;FEE�SUMMARIY:
it Is issued,I shall not employ any person in any manner so as t m 11„
'
O W become subject to the Workers'Compensation Laws of Califnmla. BUILDING
Uale Applicant ALTER OR ADD TO MECH. 4.00
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex-
).-. ? emption,you should become subject to the Workev 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 10,11MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pOf141FM.) 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.) 4.001MICROFILM
3097,CN.C.). .
+
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.P.50 ELECTRIC02 -�
Lender's Address
I certify that l'have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and countyBOILER•COMP(3.H.P.or 100,000 B.T.U.) 4.00 PLUMBING
mAin...ex and state laws relating to building construction, and
hereby authorize representatives of this City to enter upon the - BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Eabililies,judgments costs and expenses which - CONST.TAX
may in any way SEC at id ily in consequent of he PERMIT ISSUANCE 3.00
'n his pe MECH:CONT. LIC.NO. TOTAL j fl FtY:
TOT�QL
Signature of App' nt/Contractor. e s I i' 0
OFFICE COPY