4074 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT MBER
BUILDING APPLICATION & PERMIT
4074
�� ADDRESS
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER' •(/�_ PLAN CHECK VALIDATION ,
1p NAME CITY. ELECTRIC PERMIT FEE
V rE
CONI
RA OR's
NAME ZO'OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'6 APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6 DD PLAN CHECK FEE P.C.NO,
OR
ENGINEER ' -
' Llc.rvo. SIGNS TRANS. 3.00
nue Ess ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 ^ '
AMOTORS SEE FEE SCH.
ADDRESS DREss
SERVICE CHANGE 10.00 i�3
0 0 o LICENSED CONTRACTORS DECLARATION '- -
<v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H Q vNi (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H z Professions Code,and my license is in full force and effect. El ❑ ❑ ❑
0 C w G License Class Lic.Number - ,
Date ontr
Cactor
a Ys UILDING PERMIT
5 or er ¢ OWNER-BUILDER DECLARATION INFORMATION
wo A O MISC.— REFER TO ORD
; a w I hereby affirm that I am exempt Irons the Contractor's Licalse VA UATION $/FT.
F ;oa Law for the followingreusoo.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 16
180
Code.Any city or county which requires a permit to construct,alter' 7
QQ Q Q_ Improve,demolish,Or repair any Silicon,prior t0 its Issuance,also ELEC.CONTE. LIC.NO. ELEC. ��'p� /� O V
O LL requires the applicant for such permit to file a Signed statement that TOTAL P/Li ❑/p�r{yp PERMITTO
w8 he is licensed pursuant to the provisions of the Contractor's License uC Ln�
HiQ Law(Chaplet 9(commencing with Section 7000)of Division 3 of the L
14 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
rc I- the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
dF, by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
.fact more than five hundred dollars($500).)://
❑ I,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 wo4��t md4he tr psora is not
intended or offered for sale(Sec. 70449 ds' Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does'nbp'ppl)d to an owner of
property who builds or improves thereori,ehd whodoes such Work FIXTURES-PER TRAP 4.00 $0.FT FLOOR AREA TOTAL ACREAGE
himself or 0(rough his own employees,provided that such improve-
• mentsare notintended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or in, . . .
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 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 contructHos)licensed Pursuant to
the Contractor's license Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,B.&P.C.for this WATER HEATER W/VENT 4.00
reason�/_ t
Uaro /7._.�_ _� `; WATER SYSTEM 4.00 ACC.DATE ACC.FILE No.
;10WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm (hat I have a certificate of Consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerlified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SHRINK ENERGY T-24
Z O A❑IILCnaified copy is filed with the city inspection division. MISC.- REFER TO ORD, y❑ N❑ V ❑ N[]
' 2 T CERTIFICATE OF FXEMPI'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LLI COMPENSATION INSURANCE PLG.DONTR. LIC.No. PLG.
d o (This section need not be Completed if the permit is lot one TOTAL Y❑ N❑ Y ❑ No
0 Z hundred dollars(SI00)or less.)
L) O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Californiu.
a Date Applicant _ ALTER OR ADD TO MECH. 4.00 BUILDING
>_ N NOTICE TO APPLICANT: IL after making this Certificate of Ex-
2 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
fJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.EM.) 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's AddressCAV
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 100
information is correct.I agree 10 comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon (lie BOILER-COMP (Over 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 whichPERMIT ISSUANCE' 3.00 CONST.TAX
may in any way accrue against Said City in consequence of the
granting omit. MECH.CONT. LIC NO. MECH. ,
/ IOTA` TOTAL
Signazu pplieam/Cont C r ate
OFFICE COPY