3549/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NU
BUI LDI NG PROJECT I DENTI FICATION
R
i ryanolNc APPLICATION & PERMIT
�IJ�Ef0 clec.�i lQ BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 3549
OWNER'S
N ME PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
1 A) �f�. >iFSP%�.. PHDNE�19s'-4>/
NAMCONTRACTOR s UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00 -
noo ess TORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
NGINEER
LIC.No. SIGNS TRANS.' 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP / rrEMP.METER OR POLE INS. 15.00 -
APPuc4Nrs
ALICAANT DR MOTORS SEE FEE SCH.
f /1
�70 _p4/2�VN y�K SHd1U' /! Q SERVICE CHANGE 10.00 f�
woo LICENSED CONTRACTORS DECLARA 80
/SI
< U w I hereby affirm that I am licensed under proviiio ss I"Lhap(er J A' (SSU NCE DATE
y Q (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG, MECH.
H O z I'ro(essions Code,and my license is in full force and effect. ❑
z O 9- License Class Lic.Number ❑
2 m :w Dale Com ❑
a ractor 1f
x 5 � MAY
BUILDING PERMIT
Lr a a OWNER-BUILDER DECLARATION
u+O INFORMATION
w ; a- I hereby affirm that I am exempt from the Contractors License MISC.- f Co Q 11®ER TO ORD
m VALUATION SIFT.
H - mom Law for the following reason.(hTequiresa Business tocodProfessions PERMIT ISSUANCE 6.00 -
Code:Any city or county which requirespermittocoi suacl,alter,
Q G improve,demolish,or repair any structure,it(arprior to its issuance,also ELEC.CONTP. LID.NO. ELEC, ; / �ff7
A wDLL requires the applicant for such permit to file a signed statement that TOTAL Oc/ PERMIT TO
$m he is licensed pursuant to the provisions of the Contractor's License• r ;1
r 2 Q Law(Chapter 9(commencing with Section 7000)of Division 3 at the T� P
S 4 D Business and Professions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE IS,44r
IF H 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s3 _ by any applicant for a permit subjects the applicanI to a civil Penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP - 4.00 50.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-I INC.4 OUTLETS 4.00
or improvemem is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im - . - .
RES IND LOG PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner at the property,am exclusively contracting with . ❑ ❑ ❑ ' ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business 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 ILAWN SPRINKLERS-OVER 5 MA.) 1.00
contracthe Cotsfor ctor'shcenects Lwith acontmctar(s)licensed pursuant SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ 1 o exempt under Sec. .&P.C.for this
reason W i�' _1y �' 'J � WATER HEATER WIV ENT 4.00 .
Date r- 6 G '_L' WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ceril-ed
Copy thereof(Sec.3800,Lab.CJ.
Policy No. ' Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z O ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant V N V N
� y CERTIFICATEOF IiX1iMPTION FROM WORKIiRS• PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UL.
Lu > COMPENSATION INSURANCE PLG.CONTR, LIC.NO, PLG.
CIL Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑-
hundred dollars(S 100)or less.)
U O 1 certify that in the perfomance,of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
ly F mil is issued,1-shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK-
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.1 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10SWC.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 this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC C.,21to,d
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct, 1 agree to comply.with all city and county PLUMBING
oninances and state laws relating to building construction, and BOILER COMP H.P.Dr 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter 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 any way ace a ams id City in consequence of the PERMIT ISSUANCE 3.00
gmnl' OI I pen MECH.CONT. LIC.NO. MECH.
IA q'4-1 TOTAL TOTAL
Sig tore of Applicant/Contractor- Daze
OFFICE COPY