7063 I _
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT n O n
Amoucss - _ _ I b
Z 46 _ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
EWNEHS - - -
AME PLAN CHECK VALIDATION
N
OTY. ELECTRIC PERMIT FEE
NAMpRAcrrMs - UTLETS-SWITCHES-RECEP' 5.00/1.00
LIc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
11ACrOs
AOum PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS' _ 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS BOO PLAN CHECK FEE P.C.NO.
ENGINEER '
LIC.No. SIGNS TRANS. 3.00
,Asea Ess ENG. SPECIAL CIRCUIT - '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AEMOTORS SEE FEE SCH.
ADDRESS
r. SERVICE CHANGE pp,D 10.00 tIASNVE
DICTO OLICENSIiU COND3ACI OItS DECLARATION
au I herehy otiosehat I am licensed under provisions of Chapter'9 e1z w (commencing with Section 7000)of Division 3 of the Business and - ATE
F m 2 Pmlruioni Code,anJ my license ie in full form anJ c((ecL a J H)al s 6-4-T. BLDG. ELECT. PLG: MECN.
zo i m W LicwLsc Clan Lie.Numhcr n el klpv '��a: El
F ,A f IN Daln Cont motor C1�Y O VuP n'1
M , `7 BUILDING PERMIT
It ,w u OWNER-Bull-DER DECLARATION INFORMATION
a'xs;LL w I hereby affirm that I am exempt from Ile Contractor's License MISC,- REFER TO ORD ^
VALUATION S/FT.
F LL o j Lew for the following mann.(Sec.7031.5,Rosinessand Professions PERMIT ISSUANCE 6,00
C(rove,y city ormulish county whiny str a tune,prior to isconstruct,,also VX
s, Q improve,demolish,or repair any structure,prior to its EwanCv,also ELEC.CONTR. LIG NO. ELEC.
a. D 5/11
e: reclaims,the applicant fur such pemlil to file a signed statement that TOTAL PERMIT TO
w >� he is licensed pursuant to the provisions of the Contractor's License
rzQ
Law(Chapter 9(commencingwith Section 70130)of Division 3 oftle
iO Business and Professions Cale)or that he is exempt therefrom and, QTY. PLUMBING PERMIT FEE
T I- $ the basis far the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u _ by any applicant for u permit subjects the applicant to a civil penalty
of not more than live hundred dollars(S5000.) ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT.DEVICE 2.00 - OCC.GROUP RES.UNITS,
their sole compensolion,will do the work,and the structure is not
intended or offered for sal, (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cod,The Contractor',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 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employes,provided that such improve
menti are not intended or offered for sale.IL however.the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is whl within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00
builder will hove the harden.(proving that he did not build or inr BUILDING USE
prove for purNw of sale.). INDUSTRIAL WASTE INTER4000 RES IND CON FB Olney
CII,as owner of the property,am .exclusively contracting with ❑ ❑. ❑ • El 11
licensed contractors to construct the project (Sec.7044,Rushee, 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 contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT ' 4,00 -
reawn
owner -(�--. Dal • WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
.�
WORKERS'C SI IiNSATION DISCLARATION WATER TREATING EQUIP. 4.00 '
I hereby affirm that I have a certific tv otcnnsent to self-insure,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Se,3800,Lab C.).
Policy No. Company
•O ❑ Certh1cdc.pyishccchyf.....shed FIRE SPRINK ENERGY T-N
_Z Z ❑ Cerlif sed copy is mod with the city inspection,division.
OApplicant MISC.- REFER TO ORD. YE:] NE:] Y E] N�
~ y PERMIT ISSUANCE
Lu CIiR'I'I FICCOI IPE I AK JO I'INS FROM WORKERS' 5,00 - FLOOD ZONE A.L.u.c.
CL COM not be ons INSURANCE PLG.CONTR. LIG NO. PLG. ❑ ❑ ❑ ❑
Z) Z ('fhis dollsuis mead not hu completed it the permit is for ms TOTAL - sY N Y' N
hundmd dollars IS 100)or Icss.j
U O 1 certify that in the perfommnce of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner sn is to
"O W become subject to the Workers'Compensation Laws of CaliOunia.
Q. Date-Applicant ALTER OR ADD TO MECH. 4,00 / BUILDING
>_ 0NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'ComlperYti m APPLIANCE 4.00 PLAN CHECK G �Z
provisions of the Labor Cal, you must forthwith comply with U FEE' /such provisions.,This permit shall be domed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
C0NS'fRU(7ION LENDING AGENCY .' AIR HANDLING UNIT(OVERI0=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Uy performance of the work for which this Permit is issued(Sea HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT(OVER I D0,D00 B.T.U,17.50 - /�
Lender's Add. HEATING
I certify that I have read this application and state that the above VENTILATION'FAN (SINGLE) 3.00
information is•comct. I agree to comply with all City and county PLUMBING
r ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hefcby eu0mrize nepm.otatives of this city to emer upon the 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 which CONST-TAX
may in my way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gran ' fthii 'L MECH.CONT, I.C.NO. MECN.
TOTAL TOTAL L3Ss�z
Siyu[ure of Applicant/ mare r ate -
OFFICECOPY