5432 APPLICANT TO FILL IN INFORMA N WITHIN RED LINES - USE BALL POINT PEN ONLY
A - BUILDING PROJECT I DENTI FI 'ATI PERMIT NUMBER
)/ noon':: �r�p APPLICATION & PERMIT 5 A n
olQ /r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL /.�, G
OWNERS � 1{' PLAN CH ECK VALIDATION
ELECTRIC PERMIT '']`, FEE
fY/L�/ PHONE �
CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/100
IC.N (` 1 L HTING FIXTURES 5.00/1.00
CONTR TORS APP NCES-RESIDENTIAL 4.00
-y( II
J PANEL 5.00 DATE OF APPLICATION
ARCHITECT n D�rJ.��`� SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER -
- LIC.rvo. SIGNS TRA 3.00
ARCH.ss ENG. - SPECIAL CIRC 5-UB PERMIT VALIDATION
2Iv EMP.METER OR LEINS. 15.00
APPLICANT
ADDRormESS - MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00cr
w o o LICENSED CONTRACTORS DECLARATION
'o W
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢A (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m iva
Professions Ca n Iiccnse is in full fo and cIfpc}.p ,tet
Z o m- Licenx Class�i. rI -Lic.Number- � 1:11�•X'!I
2 r r Dy Ua[e Contractor
a y s i .. BUILDING PERMIT
m w¢ O NER-BUILDER DIS A IONN'FORMATION
wow. MISC.- REFER TO D -
; -t- I hereby affirm that I am exempt from the Con!raclor's License VALUATION
LL o¢ Law for the following reason.(Sec.703 L5;Business and Professions PERMIT ISSUANCE 6,00
Fy0-1 Code:Any city or county which requiresa permit to conslmel,alter,
w<Q improve,demolish,or repair any stroClum,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
F > Law(Chapter 9(commencing with Section 70001 of Division3ofthe ,I��Yy�", sy`5. 1.^55,.�.+k:r sI ' +-a o t �L(J/x•/IQ /N Cr
i o Business and Professions Code)or that he is exempt therefrom and wDSTj {.yF",fyariYBLUMBING(PERMIT s
"Aft
t
¢H o the hands for file alleged exemption.Any violation of Section 7031.5 IIFa, rr T •�`t 'h! } STORIES TYPE CONSTR.
d;m by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&V EN ATER EA.1 4.00 -
of not more than five hundred dollars(f50OL):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure u not
intended or offered for sale(Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work, FIXTURES-PER TRAP 4.00 SG,FT.FLOOR AREA TOTAL ACREAGE
himself or through h¢own employees,provided that such improve-
mentsamnotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
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 Pe Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ '❑ ❑ E] ❑
❑ 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 contme orfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&Pbc.for this WATER HEATER W/M6i1T 4.00 (J
mason
Owner Date WATER SYSTEM 4.00 47, ACC.GATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TRE UIP. 4.00
1 hereby affirm that 1 have a certificate of Consent to self-insure, ::� ZONING ENG.SITE NO.
or a Certificate of Workers'(7 alion Insurance,or a certified
7L O,. lemof(Sec.3 a .C.) - q �'1
p -
cof o. CompCmnpany F/ ,
O 0
Certified copy is hereby m d. FIRE SPRINK ENERGYT-24
Z Z fir. Cert' I d file I he - spection division. MISC.- cityo upe FER TO ORD. -
(fppbeantV ❑ "❑ V ❑ _ "❑ r
y fliRTI PICEMI'I'ION FROM WORKERS' PERMIT ISSUANCE 6.00 6 FLOOD 20NE aL.u.C.
lJJ >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO, ALG,
CL O 41his section need not he completed if the permit is for one TOTAL 3� Y❑ N❑ Y❑ N❑
Z hundred dollars(8100)or less'.) - .', ,+• 's " "
U O 1 certify Ota1 in the performance of the work for which this per PI' `' p, .„� FUMMARY-, '
IL F not is issued,I shall not employ any person In any manner so as to UTaY: y'F ..;MEaCHANICdE;P'ERMIT s lgj FlaEE`,' 9EEiS •w.vw,crn4 -
U become subject to the Workers'Compensation Laws of California.
y Dmc Applicant ALTER OR ADD TO MECH. - 4.00 BUILDING
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F' 2 emption,you should become subject to fire Workers'CompensationA LIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
such provisions or this permit shall be deemed revoked. AIR DLING UNIT(TO 10f)MC.F.M.) 3.00
CONSTRUCTION LENDING AGI?NCY AIR H LING UNIT(OVER 10MOC.F.M.) 5.00 SEISMIC FEE
I hereby affirm firm there is a construction lending agency for EXHAUST OOD(WITH DUCT) 2.00
jhe performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UN TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT( ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN INGLE) 3.00
information is correct. I agree
rel tcomply with all city and county PLUMBING
ordinances and slate lows relating to building construction, and BOILER-COMP-I3 H.P.ort bQ,000 B.T.U.) 4.00
hereby auomrize representatives of this city to enter upon the BOI
above-mentioned properly for inspection purposes. LER-COMP(Over 100,000 U)SEE FEE SCH. MECHANICAL
-
(We) agree to save, indemnify and keep harmless the City of MISC.- RENR TO ORD. .
Cupertino against liabilities,judgments;costs and expenses which CONST.TAX
may in any way accrue ngai Id City ix
n conq nce f the PERMIT ISSUANCE 3.00
li o(lhi omit MECH.CONT. - LIC.NO, CN. •.
TOTAL TOTAL
$ignat re of pplicant/ onlractor at
OFFICECOPY -