7237 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
aUILDING APPLICATION & PERMIT 3
S
q ADDRESa J
DING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'aPLAN CHECK VALIDATION
"AME •, ,�.;". -ELECTRIC PERMIT - - r `FEE
PHONE
coNrRAcro s UTLETS-SWITCHES-RECEP 5.00/1.00
NAME I I
LIGHTING FIXTURES 5.00/1.00
CONT A R' PPLIANCES-RESIDENTIAL 4.00
ADORES {�/J/��
L IG`�4H NE PANELS 5.00 DATE OF APPLICATION
ARCH EC - SIGNS S.DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nnuness E"0' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTSMOTORS SEE FEE SCH.
AooREss
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION _ L
a La u U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
P, a"' (commencing with Section 7000)of Division 3 of the Business nd BLDG. ELECT. L MECH.
F m i Professions Code,and my license is in full forrrtmdTJ' c. ❑ ❑ ❑
Z o m— License Class _ .Ic.Nwnbcr -f 0
Q m F w Dale_ TL -ontractor
a m �•'r BUILDING RMIT.. .
¢ ¢ w N:R-BUILDER DECLARATIO INFORMATION''
w S n I- 1 herebyaffirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
° P VALUATION SIFT.
r u o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
3 �;� E Code:Any city or county which reyuires a permit to construct,alter, ELEC.CONTR. LIQ NO.
¢ a a o improve,demolish,or repair any structure,prior to its issuance,ulso ELEC.
O ¢ minims the applicant for such permit to file n signed statement that TOTAL P MIT TO
'•v, " he is licensed pursuant to the provisions of the Contractor's License
F z t Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
f ¢D
the basis for the alleged exemption.Any violation of Section 7071.$ ECONSTR.
STO IES T
i ; � by any applicant for a permit subjects the applicantto a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of nol more than five hundred dollars(8500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their wle compensation,will do the work,and the structure Is not
- intended of offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 t
Code:'The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- '
GAS q.00
meats are not intended or offered for sale.If,however,the building
or improvement is sold within one year M completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder Will have the modea of proving that he did not build or inn- -
proveforpurposeofsaleJ. INDUSTRIAL WASTE INTER. 20.00 5 IND CON PS Omer
❑ 1,as owner of the properly,am exclusively contracting with C] 1:1 ❑
licensed contractors to cem,tnmt the project(Sec. 7044,Business - LAWN SPRINKLERS- 1 INC 5 V.B. t 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Conlmctor'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
can imets for such projects with a contmclods)licensed pursuant to
nr
the Contracl 's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iamexemptunder Sec. .B.&P.C.for This WATER HEATER W/VENT 4.00.LUX
,",on
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent¢r self-insure, ZONING ENG.SITE NO.
or a certificate of Wo rs'C III T I Sufaa- 11
e 3 . ). (1Ian[Il'1l/lj,`.IE'(, 'v�3/ff
O ) C p I y u hed. f FIRE SPRINK ENERGY T-Z4
❑ Cer(if A is fit d i 1 c'y ' ion di isi
zz0 APP11Cant I MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
Cr Cli 'I CATIi OF F: IiM PTION PROM WORK T:RS'
LU O COMPENSATION INSURANCE PLG.colviR. LIC.NO. LG
.AL 1 v❑ N❑ Y❑ N❑
Z (This section need not be cornpleted if the permit is for one
hundred dollars IS 100)or less.) I
U O 1 certify that in the performance of the work for which this Per- •QTY'. MECHANICAL PERMIT FEE
suFEE SUMMARY
LL F mil is issued,1 shall not employ any person in any manner so as to
U become hject to the Workers Comnsa
petion Laws of California.
y Datc Applicant ` ALTER OR ADD TO MECH. 4.00 BUILDING
>_ N NOTICE'1'O APPLICANT: If,after making this Certificate of Ex.
F Z
caption.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
lmov¢lons of the Labor Code, you most forthwith comply with FEE
U such provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 104100C.F,M,) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which(his permit is issued(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender;Name HEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
lander i Address
I certify that 1 have read(his application and state that the above VENTILATION FAN(SINGLE) 3.00
information is come(. I agree to comply with all ct I and county PLUMBING
ordinances and state laws reading to building construction. and BOILER- OMP(Over
00.000 B00 B.T.U.) 4,00
hereby authorize representative of this city to enter upon'the BOILER-COMP(Over l00,0008TU1 SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agnse to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Babiltties,judgments, sts and espenses which CONST.TAX
may in any way true against said In comeyucri f t e PERMIT ISSUANCE 3.00
11 Nag of Ibis 1. -� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
S of p i [meter Da e
OFFICE COPY