5981 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMITNUMBER
UI ,
BLDING APPLICATION & PERMIT
PDURE55
BUILDING •-ELECTRICAL-PLUMBING-MECHANICAL 1
OWNER' �-7�6 - PLAN CHECK VALIDATION
PHON
NAmE QTY. ELECTRIC PERMIT FEE
NOMTRAcrons 1UTLETS-SWITCHES-RECEP 5.00/1.00
T uc.NO. LIGHTING FIXTURES 5.00/1.00
ADD E55TORs PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT /�,�,7 �1 PLAN CHECK FEE P.C.NO.
OR ✓- ��/4q.r (�'ei / r SIGNS 6.00
ENGINEER l�V/� T/r� '
UC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. / PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
V J �r O EMP.METER OR POLE INS. 15.00
AIPLICADDRESS s
AMOTORS .(J,W SEETEE SCH.
SERVICE CHANGE 10.00
w
00 LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that l am licensed under provisions of Chapter
v,a y ICummcncing with Section 7000)n(Division 3 of the Business and ISSUANCE DATE
.
r w Professions Code,:mmy license is in full force and effect. ELCT PLGM H.. ❑
License Clan Lic.us t In n
Uatc Conticer,
ractor
BUIL INGP RMIT
¢ ¢ w a
OWNER-BUILDER DECLARATION '
A o A o MISC.- REFER TO ORD INFORMATION
w g y 1 hereby collo that I n exempt from the mess.clor's License VALUATION
u o j Law for the following reason.(Sec.requires
a,permit
toe nA Professions UFT.
� - PERMIT ISSUANCE 6.00 --
Code:Any city Or county which struiture permit toconsuanc,also
2 re c p Improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - ELEC.
Cr¢ requires the applicant for such permit to file a signed statement that _ TOTAL
W m he is licensed pro,...I In the provisions of the Contractor's License ` PERM I TO
HiQLaw(Chapter 9(commencing with Section 7000)of Division Sof the
4 o
Business and Professions Code)or that he is exempt therefrom and O PLUMBING PERMIT FEE (/ l
¢ r m the has for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
a3_ by any applicant for a Permit subjects the applicant loacivil penally ALTER-DRAIN -WATER IEA.) 4.00 of not more than five hundred dollars(S500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP
their sole compensation,will do the work,and the structure Is not RES.UNITS_
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:I'lie Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work ,2- F IXTUR ES-PER TRAP 4.00
himself or through his own employees,provided that such improve- sa Fr.FLOOR AREA TOTAL ACREAGE
meets arc not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner- ItGAS-EA.SYSTEM-OVER 4(EA.)
builder will have the burden of proving Thal he did not build or ire- 1.00 BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.10 ❑RES 'IN ❑ Other
❑ I,as owner of the properly,am exclusively contracting with
licensed crntraclrrs to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The C'ontractor'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
C t cts for such projects with a contractor(s)licensed pursuant to
Un onlractors license Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
I am exe pt under Se ,B.&P.C.for this 4
I_ _ U WATER HEATER W/VENT
Owne ])at WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK I' S'COMPI? :ATION UGCLARATION WATER TREATING EQUIP,
I hereby affirm that 1 have a Certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thercof(Sce.3800,fah-C.f
Policy No. Company
U 1 ❑ Cer(ilied copy is hereby furnished ,
z- ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-24
F - Applicant MISC.- REFER TO ORD. Y0 NEIY [ N�
w CER'I'IFICAT E OF EXEMVIION FROM WORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A.L.U,C.
W COMPENSATION INSURANCIi PLG.GONER. LIC.NO.. PLG. /
n' O Chis section need not be completed if the permit is for one TOTAL �FV Y❑ No Y 0 N
Z hundred dollars IS 10(por les.)
U O 1 Certify Gat in the performance of the work for which(his Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.Lshall not employ any person in any manner sI as n
O ED become subject to the Workers'Compensation Laws of Ca1d'ornia.
y
Dale.Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE'1'O APPLICANT: If,after making this Certificate of Es-
F Z caption,you should become subject to(be Workers'Compensation APPLIANCE r 4.00 PLAN CHECK
provisions of tie Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10J=C.F.N1) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.F.M.) 5.00 SEISMIC FEE
I hereby elfin. that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec.o97,
3MICROFILM
Civ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
3097,Leadc's Name
e
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 q/
information is correct, I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construdinn, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 _ �w'
hereby entioniac representatives of this city to enter upon thauthore BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. c
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless (he City Of MISC.-. REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 --
gmntingofIusper mil. a MECH.CONT. LIC.NO. MECH.
TOTAL
7W o/�
LlSilma ore of plicant/Con ctor Dal TOTAL J
OFFICE COPY