4437 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER_]
BUILDINGAPPLICATION & PERMIT 4437
aooREss
LID -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - - PLAN CHmJk5ATION
f, NAME/A,�J QTY. ELECTRIC PERMIT FEE �rAA u
^r ORS HONE ' 1^
NAME
CONTRACTOR
Name - (jILD d UTLETS-SWITCHES-RECEP 5.00/1.00 y r 1983
X uc.No. 55 fu 2 LIGHTING FIXTURES 5.00/1.00
CONTRACADDRESS Ti All- APPLIANCES-RESIDENTIAL • 4.00. Cltf Of Cupertino
X ! ONES 7, PANELS 5.00 DATE OF APPLICATION
A CHITECT PLAN CHECK FEE P.C.NO.
on SIGNS 6.00
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
aooeess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
APvucarvrs ZIP TEMP.METER OR POLE INS. 15.00 AoORcss MOTORS SEE FEE SCH. `�O
1 SERVICE CHANGE 10.00 �(\
O¢ 2' \Vl✓
Hoap .LICENSED CONTRACTORS DECLARATION '
a u y I hereby affirm that I am licensed wider previsions of Clmpter 9 - ISSUA AT
a Q y (commencing with.Section 7000)of Division 3 of the Business and BLDG. E EC PLG. MECH.
H w i Professions Code n�any license is in full force et ❑ ❑ ❑
2 o m - License s o4d sec.Number
0 �w Dae-Z- �- Contractor_
BU ING PERMIT
¢ ¢ w OWNER-BUILDER DECLA ATI N INFORMATION
wo u w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 u Y p VALUATION $/FT.
H u o j Low for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
Be ¢Q p Improve,demolish,Or repair any dfact ure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
A m¢ requires the applicant for such permit to file a signed statement(hal TOTAL PER MIT TO
w he is licensed pursuant to the provisions of the Contractor's License
Law,(Chapter9(commencing with Section 7000)of Division 3ofthe
4 o Business and Professions Code)or that he is exempt therefrom slid DTV. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a � by any applicant for it Penni(subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($5001):
❑ I,as owner of the properly,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 sl ructure is Bre
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 $O,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided(hat such improve-
mentsare not intended ooffered far sale.If,however,The building 'GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 G USE
(EA.) 1.00 BUILDING builder will have the burden of proving that he did not build or Inc- RES IND CN PB Omer
11 1,
for purpose ofsale,I. INDUSTRIAL WASTE INTER. 2000
I,as owner of tire .
e property,am exclusively contracting wills ❑ ❑ ❑ ❑
licensed contractors to construct file project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 -ASSES So sPARCEL NO.
and Professions Code:The Contractor's Licens:Law does not apply
to an owner of property who builds or improves there...,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
" or a celidlCilt of Workers'Comp no i m Ins",nee, sy.rlil"-
/I` copy there I e ))((pp PN
Policy No. �I,y -_AANA
O ❑ Certified copy is hereby I rnished. �,,vvrr'' FIRE SPRINK ENERGY T29
❑ Certifjyl, copyf/s�filed wirli the city inspect ion division. MISC.- REFER TO ORD.
Z p ApplicV❑ N❑ V ❑ No
� y CII RTI FICATE OF EXEMPT ION FROM WORKS RS' PERMIT ISSUANCE 6.00 .FLOOD ZONE A.L.0 C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y[3 N❑ V C] NE]
Z (This section need not be completed if the permit is far one TOTAL
hundred collars($I00)or less.)
U O 1 certify that in (he performance of ore 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 es to
O W become subject to the Workers'Compensation Laws of California.
ad
Date-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
Y W NOTICI7 TO APPLICANT: If,after making this Certificate of Ex-
♦- Z emption,you should become subject to the Workers'Compenmtion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U srlch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10j,D0 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.F.M.) 5.00 SEISMIC FEE
I hereby affirm Ihat 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.). HEATING UNIT (TO 100,0000.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree 1.ti comply with all city ucti county PLUMBING
ordinances and stale laws relating to building 1 city and. and BOILER-COMP(3 H.P.or 100,0008.T.U:1 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menlioned 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
Boy m try way n zoic against said City in comuquence of the PERMIT ISSUANCE 3.00
gr Hi of this pen MECH.CONT. LIC.NO. MECH.
' /D-7-6TOTAL TOTAL
Sib ature of App e, lContruci Date
OFFICE COPY