5281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
HDILDING APPLICATION & PERMIT
_ 5281
ADIIRESS y
13, O WE BUILDING-ELECTRICAL-PLUMBING-MECHANI
.EH'S - PLAN CHECK VALIDATION
" E /�TL� DTE. ELECTRIC PERMIT ` '� FEE'.
4� (o w PHONE'V�-�E
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
"AME
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 -
ADDRESS
PHONE PANELS 5.00 1 DATE OF APPLICATION
ARCHITECT SIGNS g,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
'ADDRESS E"D - SPECIAL CIRCUIT 5.00 PERMIT VALIDA///7771ON
ZIP EMP.METER OR POLE INS. 15.00 I
ARSMOTORS' SEE FEE SCH.
S
ADDDDREESS
SERVICE CHANGE 10.00 ?/
o o LICENSED CONTRACTORS DECLARA'f10N -
I[ u 1 hereby attain that I am licensed under provisions of Chapter 9 ISS N E DATE
Q m (commencing with Section 7000)of Division 3 of the Business and
Q n ' BL ELECT, PLG. MECH.
r m i
Profession,Ch C«Ic,and my license is in full tome and effect. ❑ ❑ ❑
Z, o m - License Class Lie,Number - r
Si, Dam Contractor - A q 7
2 Q owNEk-Buanr:R DECLARATION MAR 2 I BUILDING PERMIT
C
a o _ MISC.- - R ER TO ORD INFORMATION:.
w 3 A 1 therebyaffirmthat 1 am exempt from the Contractors License VALUATION s/FT.
H .. o Caw
the following
re VALUATION 703 1,5,Busincssand Professions PERMIT ISSUANCEviry Or
8
--' Code Any city or county which requires a permit to Construct,alter. �,[
ce u'Q 0 improve,demolish,orrepair any Structure,prior to im issuance,also ELEC.CONTR. LIC.NO. ELEG. ��/ O O
Et ¢ rrgaires the applicant for sueh.pernit to rile a signed statement that - - TOTAL PERMIT TO
K
he is liceosed pursuant to the provisions of the Contractor's Liecow �7
Fzi Law(Chapter 9(comme,c'mg with Section 70001 of Division 3 of the E�OOF 7CG.0
Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
a.�r
of not more man Five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Side (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 .2 g
Code:The Contractor's License Law does not apply to an owner of •Z sT �"'F . e
PR,Nrly who builds or improves thereon,a ad who docs such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inlprove-
,� norms are not intended or offered 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-EA.SYSTEM-OVER 4 IEA.1 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ice- R IND CON PB Do.,
for purpose of sale.). . INDUSTRIAL WASTE INTER. 20.00'
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or innproves thereon,andwho 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.
❑ la 1 exempt under SC ,H.&P.C.mrthie WATER HEATER W/VENT 4.00
reason n
Owner_ _ Cie! Date WATER SYSTEM 4.00 ,ACC.DATE ACG FILE NO.
WORK ERS'COMPENSA IION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby iff,nt that 1 hove a certificate of consent to ,If-insure, '
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO-
copy tltcrcof(Sec.3800,fah(:.)- '
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified c.p,*i, filed with the city inspection division. - .
O Applicant MISC.- REFER.TO ORD. Y ❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 6.00
LU - CER7'1EICA'1'8OPIi TION INS RAN WORKERS' FLOOD ZONE A.L.u.c.
W COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Y❑ N❑ Y ❑ N❑
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this Per GTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any mannerSo as to
O becmne subject to the Workers Compensation Laws of California. -174
Sb
ED ate
D ' - Applicant ALTER OR ADD TO MECH. : 4,00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? eruption;you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor,Code, you most forthwithcomply c mply with -
U
Rich provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE ,$-O
I hereby affnG that there is a corlstructwri lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM.
San,Civ.c.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree 1.comply with it elty and county PLUMBING
ordinances and state laws relating to building Construction, and BOILER-COAT(3 H.P.or 100,0008.T.U.) 4.00
hereby authonce representatives of this city to enter Linn, the BOILER-COMP (Owe 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for Inspection purpose.
'(We) agree tD save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs end expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue st sad City in conseymem¢ of the
gra`rrryyyJmg of this�qe rmiL MECH.CONT. LIC.NO, MECH.
Y�1LQ' l., " TOTAL TOTAL gCS�.
Signature o f Applican /Contractor Date
OFFICE COPY