4419 APPLICANT TO FILL IN INFORMATION,WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BU I LDI NG PROJECT I DENTI FICATI ON
I BDILDING APPLICATION & PERMIT 4-419 A r� [�
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ., PLAN CHECK VALIDATION
AMF
YYYYYY) QTY. ELECTRIC PERMIT FEE
PHON
�'cAN>ERAcrons UTLETS-SWITCHES-PIECED 5.00/1.00
1�c�Tt11�7 uc.rvo,l-7�..A7.J� LIGHTING FIXTURES 5.00/1.00
CONTRACTO ' f� 1 ppLIANCES-RESIDENTIAL 4.00
ADDRESS 1 , _��{{//,�J� (0 ((]1��
r PHON(,J�I� J PANELS 5.00 DATE OF APPLICATION
ARCHITECT - , SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
• 'uc.NO, ' SIGNS TRANS. - 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS - /
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION
rt u uI hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N.Q H (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z Professions Co an ensu is N#LARATION
❑ ❑ ❑
z o w- Licen ` ,'�Co
No -
o m Date L $1 Contra
a m M BUILDING PERMIT
E lea OWNER-BUILDER D
Ix i u INFORMATION
E
; phereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
w VALUATION S/FT.
H LL U.
Lade:Any ilyfollowingrey which
permit
ess town Professions PERMIT ISSUANCE 6.00 ,
Code:Any city ar county which structur a permit o its issuance,
alter,
R ¢Q improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTE.. LIC.NO. ELEC.
a u requires the applicant for such permit to file a signed statement that TOTAL
w$ he is licensed.pursuant to the provisions of the Contractor's License PERMIT O
I- zi Law(Chapter 9(commencing with Section7000)of Divislon3 attire
m a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
(CF $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.14.00 .
afoot are than five hundred dollars(S500t): -
❑ Las owner of the property,or my employees with wages as - BACK FLOW PROTECT. DEVICE 2.00 ocC.GROUP RES.UNITS
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
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 employees,provided that such improve. ,
meets are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 '
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder,will have the burden of proving that he did not build or im- RES IND CON Pe Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 0 El 1:1 1-1 11❑ I,as owner of th
e property.am"elusively convecting 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 Convector'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 conlructon s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ina exempt under Sec.-,B.&P.C.(or this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'.COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 hove a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certilied
policy
r 3 .C. \�`� m�. . .
Policy Y
O rtlf d py is hereby to milt d x FIRE SPRINK ENERGY T 24
Z Z IY Ce if y - di is t. MISC.- REFER TO ORD.
O Applicant e Y N� v [] N�
V3 PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
> CE I ICATE Of EXEMPTION FRO ORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTE. ❑C.NO. , PLC.
d Cl (This section need not he completed if the permit is far one TOTAL Y❑ NY ❑ IN
:3 Z h u acted dollar,11100,or less)
U O 1 certify that in the performance of the work lbs which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL P mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
0. ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F 2 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
V such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=12-F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending.,any 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'.1 4.00 -
Lender's H EATING UNIT(OVER 100,000 B.T.U.17.50
Leader's Add,Addrtss ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.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.- R R TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the SS CE 3.00
gr gof this per i.It I, E
MECH.CONE. LIC.NO. - MECH. /�-��/
����� 1 TOTAL /00 TOTAL
5 n are of Applicant/Contou
OFFICE COPY