4837 LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERM(
3� S BUILDING - ELECTRICAL-PLUMBING J
7
NNER- S LAN CHECK VALIDATION
1<1 NAME U U CITY. ELECTRIC PERMIT FEE
PHDXLG •Y/ L
NOMrERACTOes G UTLETS-SWITCHES-RECEP 5.00/1.00
- Ic.do. �� ` LIGHTING FIXTURES 5.00/1.00
CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
eooBEss �� y
-p
So.{*1cs+ PRONE_ro'-7�Y,3 PANELS 5.00 DATE OF APPLICATION
ARCHITEL IT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEE
LIC.NO SIGNS TRANS. 3.00
ADD"
"OR ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
A" zFP EMP.METER OR POLE INS. 15.00
pPPucANrs MOTORS SEE FEE SCH,
APPLICANT
SERVICE CHANGE 10.00
'02 LICENSI'D CONTRACTORS DECLARATION
M u U, I hereby affirm that 1 am licensed under provisions of Chapter') ISSUANCE DATE
a, G y (commencing�with�nSection 7000)of Division 3 of the Business anJ BLDG. ELECT. PLG. MECH.
H O z Professions ase al'odl see i- in full force' I�U.
0
, 02 - License Cla Lie Number='„ YY ❑ ❑ ❑ ❑
g v, H w ate Contractor L.
`e r s < BUILDING PERMIT
0 w < OWNIi R-BUILUIiR DECLA RA'ItON INFORMATION
AOAca MISC.- VREFER TO ORD
m ; LL n 1 hereby uffrm that 1 am exempt from the Contractor's License VALUATION S/FT.
r u o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6,00
Code:Any city or county which requires a permit to covslmet,alter,
Q0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC,
dy
K 0, requires the applicant for such permit to file a signed statement that - TOTAL p RMIT TO
$m he is licensed pursuant to the provisions of the Contractor's License
ria Ww(Chapter a(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
rc o the basis for the alleged exemption.Any violation o(Seclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toecivil penalty ALTER-DRAIN -WATER (EA.) 4.130
of not more than five hundred dollars 155001.1'.
❑ 1.as owner of the propery,or my employccs with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole com Pansalion,will do the work.and the structure n not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
ny Code:The Contractor's License Law does not apply to un owner of
property who builds or improves thereon.and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold wilhin one year of completion,lire owner-
( 1 GAS-EA.SYSTEM OVER 4 IEA.) 1.00 But LDING USE
O builder will have the burden of Arming that he did not build or int-the
RES IND CON Pa One,
prove for purpose of e.7.
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIALWASTE INTER. 20.00
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law does not apply
to an owner of progeny who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5(EA.) 1,00
contracts for such projects with a contructon s)licensed pursuymt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
mason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
r WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certiticute of consent to self-inwre,
Itoror a certificate of Workers'Cati,e"sition Insumncc,or a certified ENG.SITE NO.
copy thereof(Sec.3800.Lab.C. y
JQ-0ertilied copy u h reby
- fu>�Is V
FIRE SPRINK ENERGY T 2
z =O ( plica alit icd 'o y is tiled,with tc ci y'aspect ion divixion.cz" MISC.- REFER TO ORD. v N v [1) NE]
~ sn PERMIT ISSUANCE 6.00
� - CIiRTIE1GOMPE IiXFMP1SWION'I NS FROM WORMS'iS' FLOOD ZONE A.L.u.C.
W reed not be ION Ived if INCE PLG,CONTR. LIC,NO. PLG. Y❑ N❑ Y ❑ N❑
Z (This section need not ire compktcJ if the permit is for one TOTAL
by 1 C,ldollarsf S 1001 orIncl
U O I is issued,
this( aI l O IF employ an of person
in
far which this pct- CIff MECHANICAL PERMIT FEE FEE SUMMARY
W C) mit is issued.I shall nut employ any person in any manner is to
O W become subject to the Wodsers'Compewlion Laws of Calilomiu. BUILDING
n Dom ICAN 1:m ALTER OR ADD TO MECH. 4.00
} W NOTICE you
APP(-(CAN'T: If,after muting this rs*certificate of lix-
F.. ? pmptloq you the L bor Code, yonect totheforthWorkwith
L'co pey with APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you nest forthwith comply with - FEE
U such provisions or this permit shall be Deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LENYING AGENCY AIR HANDLING UNIT(OVER IQOWC-F.M.) 5.00 SEISMIC FEE
I hereby affrm that there a co�slkt lendingagency for EXHAUST HOOD (WITH DUCT) 2.00
the perfommnee of the work r hrmit is issued(Sec. MICROFILM
3097,Co.C.). HEATING UNIT(TO 100,000 B.T.U:) 4.00
Lenders Name H EATI NG UNIT(OV ER 100,000 B.T.U.)7.50
Lender i Addmss ELECTRIC
1 certify that I Los,read this application and slum tiro(the ahnvI VENTILATION FAN (SINGLE) 3.00
int'ouration is correct, I agree to comply with all city anJ county PLUMBING
urdi"antes and state laws relating to building construainn, and BOILER-COMP(3 H.P.or 100,0006.T.U.) 4.00
hertby untlmrirx representaifives of this city m enter upon the
BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
uhovrmcn0aned property fur inspection Pugwscs.
(We) agree to save, indemnify and keep harmless the City Of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
nray in any way accrue against said City in consequence of file
granting of this 1) nit, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
$ignatu¢of APPlicuntjContraetor ate -
OFFICE COPY