3208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL
PUILDING PROJECT IDENTI FICA710N ER MISER
BUILDING APPLICATION & PERMIT ^� 0 p
X'
ADDRESS 0
�RE�J� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAIVE QTY
CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
Mo63r[.. 0/t.-
CONTRACTORS
NAME� C !p npp �" UTLETS-SWITCHES-RECEP 5.00/1.00
7- AyUL " ,E'c'cTr LIC No. aC i ! d'n LIGHTING FIXTURES 5.00/1.00 -
/
ADDRESS oRs G!!-IQ4y APPLIANCES-RESIDENTIAL _ 4.00
CONTRACTORS h
U/00 OEWTak Av PRONr bW;?'�Q�, i PANELS 5.00 IS
DATE OF APPLICATION
RC„ITECi SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. - - 3.00
nooness AND, :sirECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS
AMOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
0
0
op
Foo LICENSED CONTRACTORS DECLARATIONCAO�eZ [, �d � 3/
Ix v I hereby affirm that 1:un licensed under provisions of Cha t r 9 ISSUANCE DATE
¢ i c Y p p e C'd
w ¢ H
(commencing with it Section of Division 3 of the Businps send SLOG. ELECT- PLG. MECH.
F w z Professions CoJ. d myy license iz in full force.Silt -
¢ z Liccnsu lass !O Lic.Number
o m F Date Contractor
Q y f J
¢ ¢ w ¢ OWNER-BUILDER DECLARATION hin BUILDING PERMIT
w ;0 a MISC.- REFER TO ORD INFORMATION
F I hereby affirm that 1 are exempt from the Contractor's License
F MAR
a. Oa Law for the following reason,(Sec.7031.5.Business and Professions PERMIT ISS NC vAwanoN $/FT.
Code:Any city or county which squires a permit to construct,alterp1p6.00
2 ¢ o p improve,demolish,Or repair any structure,prior to its issuance,also ELEC,COI G ELEC. t7d
¢ requires the applicant for such permit to file a signed statement that TOTAL /�
is
ro y he is licensed pursuant to the provisions of the Contractor's LicensePERMIT TO
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 Of the
s i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
A _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN VENT-WATER IEA.) 4.00
of not more than five hundred dull...($5001.):
❑ 1,as owner of the property,or my employees with wagesas BACK FLOW PROTECTDEVICE 2p0
their sole compensation,will do the work,and the structure is not. . ,
OCC.GROUP RES.UNITS
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law docs 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 though his own employees,provided that such improv,
merits are not intended or offered for sale.If.however.(liebuilding GAS-EA.SYSTEM-I INC,4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1,00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove 1,as ownerose
of(lie
INDUSTRIAL WASTE INTER. 20.00 RE RES I❑ ❑N �Pa O❑
❑ L as owner of the property,he rojectiv Se , 7 44. ing with
licensed contractors to construct the mecca La does Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
.not Professions Code The Contractor's License Law Joos not apply
to an cts for
of h projects
who ba commds actoosvcs thereon. who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such pmjecb wi Dl v cool rndorl s)lic'cnscd punuunl to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ lain exempt under Sea ,B.&P.C,for this 4.00
reason WATER HEATER W/VENT
Date Owner WATER SYSTEM 4.00
ACC.GATE ACC.FILE NO.
WORK IiRS'COh1PENSA'fl(1N DECLARATION WATER TREATING EQUIP, 4.00
U 1 hereby affirm that 1 have a certificate of consent to"If-insure, ,ertioyc�at�esu�f,,Workeri Compensation Insurance.or a certil'ieJ ZONING ENG.SITE NO.
Ny�lty�o.�yfjSe8c 00,,Lan.v_) T OA�t /v5, Go
❑ Certified copy hs hereby f
Z Z ❑ Cerufictl opy is tlel with -Tte�ITy� ne�ctl6A dn'ulon. _ FIRE SPRINK ENERGY T 24
FO Applicant _ MISC.- REFER TO ORD. Y0 NYr NEJ
� tb CB IPICA'I'h P EXEMP'T'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMP17NSATION INSURANCE PLG.CONTR. LIC.NO, PLG,
CL O (This section miul not be completed if the permit is for One TOTAL Y[:] N Y [:3 N
::) Z hundred dollars IS 100)or less.)
U O 1 curtily that in the performance of the work for which this per. DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, 1 shall not employ any person in any manner so as to
Uw become subject to the Workers'Compensation Laws of California.
}
a Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING 2 NO'I'IC17 1'0 APPLICANT: If,alter making this Certificate of Ex-
_ enption,you should become subject to the Workurs Compensation APPLIANCE 4.00 PLAN CHECK
provisions of tire u e Labor Carle, yomust forthwith comply with
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000CF.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMICFEE
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
Lender's Add...x HEATI NG UN IT(OV ER 100,000 B,T,U,)7.50 ELECTRIC 6
I certify that l have read this application and state 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 L nstruction, and BOILER-COMP(3 H.P,Or 100,000 B.T.U.1 4.00
hereby authori<e representatives Of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 accrue against Said City in consequence of the PERMIT ISSUANCE 3-00
gran tin f this perndl' MECH.CONT. LIC.NO. MECH.
X -3�-5k3 TOTAL TOTAL
.cure Of App hent/Contractor Uutc
OFFICE COPY
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