3940 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMI?NUMBER
\
OU LONG APPLICATION & PERMIT ^�(�n 0
ADDRESS v J T
l� BUILDING - ELECTRICAL-PLUMBING-MECHANICA -
y OWNER'S 7 LAN CHECK VALIDATION
;� �02 n2 TY. ELECTRIC PERMIT FEE
. C,aua.lo RDNE o[
tioRACT s UTLETS-SWITCHES-RECEP 5.00/1.00
L ua.IN Q�SJ LIGHTING FIXTURES 5.00/1.00
xcONTRAcm'oHs
AooREss PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHI ECT SIGNS 6 PLAN CHECK FEE P.C.NO
ENGINEER
ilc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION li
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 15.00
ANrS
ADDF MOTORS E FEE SQ
DRESS CH. o
SERVICE CHANGE 10.00 d
0 ¢ z Q
F o o LICENSED CONT RACTORS DECLARATION /O3
< u 1 hereby affirm that I am licensed under provisions of Clepter 9 G ISSUANCE GATE
Nz i (commencing with Section 71700)of Division 3 of the Business unit
< BLDG. ELECT. PLG. MECH.
O i Professions Co n licamx is in lull fore f' ❑ ❑ ❑
z o`�' - Licamsc a Li,Numbc
9 y Dme _ Cnntremor s,{
a r BUILDING PERMIT
Ii: w
OWNERBUILDERDECLARATION INFORMATION
w ;LL 1 hereby affirm that I ani exempt front the Comructor's License MISC.- REFER TO ORD
VALUATION $)FT.
Foo Law for the following mason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requirese Iwrmit to construct,allet,
is at ¢Q Improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEG
of 0 Q denudes the applicant for such permit to file a signed statement that TOTAL (� PERMIT TO
A w he is licvucd pursumd to the provisions of the Contncmr•s License
Fit Law(Chapter 9(commencing with Section 7000)ol'Division3ofthc �C �-T
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
re O the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; � by any more tha cora permit subjects the 500d.)canuoucivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollen(S5001.):
D I,as owner of the progeny,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES,UNITS
their sole Cconfriaction,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 hailds or improves thereon,and who dues Such work FIXTURES-PER TRAP 4.00 SOL FT.FLOOR AREA TOTALACREAGE
menta are oti menet ownemployees, le i f,hit ever,the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
mems are not intended w uempl for sola IL ed however,the building
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 of
inn
prove for purpust of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Omer
20
❑ 1,as owner of the property,am exclusively contracting with 0p ❑ ❑ ❑ ❑ ❑
l ict used contractors 10 construct the project IS, 7044. Basin,s 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 progeny who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such project with a contractims)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO, PARCEL NO.
❑ I um exenmt under Sec. .B.&P.C.tier this WATER HEATER W/VENT 4.00
recon
Dam Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of constant to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation [examine,[exaneor a cenif<d
Copy the mnf(Sc,.3800,Lrb.C.).
Poky No. Company
O ❑ Certified copy is hereby funtished.
RE SPRINK ENERGY T44
Z 2 13 Certified copy is tiled with the city' inspection division.
O Applicant MISC.- REFER TO ORD. y ❑ N❑ Y ❑ IN
~ va PERMIT ISSUANCE 6.00
LU
CERTIFICATE E EXEMPTION PRN WORKERS' FLOOD ZONE A.L,U.C.
UJB O need not
be com INSURANCE if NCI: PLG.CONTE. LIC.NO. [PEG I
TOTAL Y❑ N❑ Y❑ N❑
(This dollar, need not be completed if the permit is for one
Z hundred dollars 151001 or lcss.l
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
Il.. H mit is is •d, I shall not employ any perm in any manner am as m
U becul the Workers' to IS s o our
/ Dat Applican �`?= ALTER OR ADD TO MECH. 4.00 BUILDING
} to ^ NO'-C TG APPLICANT: rifer making this Certilicmc of Ex-
FZ emption,you should become Subject to the Workers 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=11F.W 3.00
CONSTRUCT ION LENDING AGENCY 'AIR HANDLING UNMOVER 10PMC.F.NL) 5.00 SEISMIC FEE
1 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.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Addss ELECTRIC
-l certify that l have read this application and state that the above VENTILATION FAN (SINGLO 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and .state law, relining to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authurim representatives of this city to enter upon the BOILER-COMP (Oxer 100,1]OD BTU(SEE FEE$CH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to are, indemnify and keep harmless the City ut MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may my ahem rgrinst s id Ci in consequence of th, PERMIT ISSUANCE 3.00
gra of tuft MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
®lawre fAm ie m/ mmemr D
OFFICE COPY