7276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI G PROJECT IDENTIFICATION PERMIT NUMBER
BUILDIN .ase APPLICATION & PERMIT
AD RES
BUILDING - ELECTRICAL-PLUMBING-MECHANICALS3
7276
OWNER'S PLAN CHECK VALIDATION
NAME I QTY. ELECTRIC PERMIT FEE
2_
Me
CON RAcroXs I NAME UTLETS-SWITCHES-RECEP 5.00/1,00
LIC No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT - • SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEERCcs ,^
Cll�� ` f ` LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ARCHERS S'A^f
A oa-'s MCI z.P sia m EMP.METER OR POLE INS. 15.00 ,x C
ADDRES 's MOTORS SEE FEE SDH.
ADDRESS
SERVICE CHANGE 10.00
f O o LICENSED CONTRACTORS DECLARATION
to r I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vaHi<vdWi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
a o w- License ClassLie Number
?w F w Date Contract.,
OWNER-BUILDER DECLARATION 8 IDIN,GtPtiE RMIT
>.o A MISC.- REFER TO ORD -(N FORMATION
K 3 LL h 1 hereby affirm that I am exempt from the Conlmclms License ,VALUATION S/FT.
LL o a Law for the following reason.(Sec.7031.5,BusinessanciProfessions PERMIT ISSUANCE 6.00
n - Code:Any city or county which mquire,a permit toconstrucUldho,
Q Q 0 Improve,demolish,or Mpalr any structure,prior to Its issuance,also ELED.CONTFU LIC.NO. ELEC. --. _
a, requires the applicant for such permit to till`a signed Statement that TOTA PERMIT TO
a m" he is licensed pursuant to the provisions of the Contractor's License
La La Law(Chapter 9(commencingw'ith Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
Do
the basis for the alleged exemption.Any violation of Section 703 L5 ORIE$ TYPE CONSTR.
a ;m by any applicant for a pennit subjects the applicant to a Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(8500).):
❑ 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 F IXTUR ES-PER TRAP 4.00 SQ.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
ments are not intended or offered for.sale.If,however,the building GAS-EA.SYSTEM-11NC.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 ire- RES IND CDN PB ofloo
prfor purpose Dl'sale.). INDUSTRIAL WASTE INTER. 20.00 El El El El El1.as owner of the Property,am exclusively contracting with
I' en ed contractors to construct 01e project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. (.
and Profession,Code'I lie Contractors L icenu Law does not uPPly
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 contractors)licensed pursuant to
the Contractor's Liceew Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l an,exempt under Sec. ,BAP.C.for this WATER HEATER WIVENT 4.00
owner Date b' WATER SYSTEM 4.00 TC C,DATE ACC.FILE No.
WURKERS'cOMPBNSA'I ION DECLARA'l1ON WATER TREATING EQUIP. 4.00
1 herchy Alin.. Ow I love I,ccrtificale of consent l I self-insure, ZONING ENG.SITE NO.
crtil'icate of Workers'Compensation Insurance,or a certified
cL
opYthc,cof(Scc 3800,Lab.C.).
Policy Nn, Company
Q ❑ Certifiedmpyisberchyfurnished, FIRESPRINK ENERGY T 24
Z_ z ❑ Certified copy is filed wish Dt9 city inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Applicant
F v0-i PERMIT ISSUANCE 6.00 DLooD ZONE a.L.u.c.
� CER'TIFICA'1'17 OF EXEM1'NON FROM WORKERS'
UJ > COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. PLG.
CL t) (Phis action riled not be completed if the permit is for one TOTAL Y❑ N Y NE]
Z hundreddo11nrs(S1000o1less.) `
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued.I shall not employ any person in any manner w as t.
U bee sybjec(to the Workers'Compensalinn Lows of California.
W DatL•�(,7 u/Sc.c'ARPlica^t C•?('�Nnl'-`Q-ID'"P �"d' ALTER OR ADD TO MECH. 4.00 BUILDING
} w NO C: A I ICAN'1': IL alt r making this Certili e : -
F Z cmption,you should become subject to tem Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of Om Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10)WOC.F.MJ 3.00
CONsrRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.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. MICROFILM
3097,Civ.C.). oS ��,E-,•C� HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
Lenders AJdres _ea N' �-pS�-/�C I'� - '
I certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
. information is correct.1 agree m comply with all city and county BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordnance, and state laws relating t. building ronstruction, and
hereby autlmri¢ representatives of this city to enter upon theBOILER-COMP(Oar 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 pERM1T ISSUANCE 3.00 CONST.TAX
may in any way Scc •,Rest sail ity i consequence of the
gra Of � permi a MECH.CONT. LIC.NO. MECH.
e TOTAL TOTAL
gnamm�of Applicant/ ontmctor Date G
OFFICE COPY