2924 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BU I LOING PROJECT I DENTIFICATI ON PEIT R
BUILDING APPLICATION & PERMITA,71 Ct _(] /�
Z ' UILDING -ELECTRICAL-PLUMBING-MECHANICAL
�7 4
OWNERPLAN CHECK VALIDATION
N +�/, QTY. ELECTRIC PERMIT FEE
ONE
No MERAcro"s UTLETS-SWITCHES-RECEP 5.00/1.00
sec.No.'J✓ LIGHTING FIXTURES 5.00/1.00 -
FONTEL9 OR'E APPLIANCES-RESIDENTIAL 4.00
O e T PRGNE)_'7 0721. PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGN$ 6.DD PLAN CHECK FEE P.C.NO.
ENGINEER
LC NO. SIGNSTRANS. 3.00
ADD'Ess G.EN5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 (�
Foo LICENSED CONTRACTORS DECLARATION J
a u t 1 hereby Afinn that I am licensed under provisions of Chapter 9
z w ISSUANCE DATE
m Q Iconrnencing with Section 7000)of Division 3 of the Business and
r H i Ptolessions`CoI `n,Lpl license is in full tura nJ c(I'" BLDG. ELECT. PLG. MECH.
z o w Lice is lass LG. Lic.Nmnber 7 [I
w w Uale Contractor y�� � l_ - tiFI
Q a, f J
BE BE BE a OWNER-BUILDER DECLARATION I BUILDING PERMIT
X 3: LL y 1 hereby affirm that I am exempt from the Contractor,License MISC.- REFER TO ORD INFORMATION
H u o so Law for the following reason.(Sec.7031.5,Businessland Professions ' PERMIT ISSUANCE vq Lunn ON g/FT.
Code:Any city or county which requiresa permit to construct.alter, 6.00
m ELEC.CONTR. LIC.NO.
o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
a w m Z requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to file provisions of the Contractor's License
Hz > Law(Chapter 9(commencing with Section 7000)of Division 3 of fire /LQe Gr�
F i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE / ( lll��/
R m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE cONSTR.
> ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).): -
❑ I,as owner at the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the structure is not
;mended a ontract for Lace feel. 7049. 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 F IXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
h imselfor through his own employees.provided that such impnrve-
mcn¢orere not intended or within onefor
year o however the theo nee. GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.0p
builder will have the burden of proving that he did not the
or im- BUILDING USE
prove fors owner of sale.). INDUSTRIAL WASTE INTER. RES IND CON BE Omer
❑ d as owner of the msTL,t he exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contradrrs to The
the Project (Sec, fee, ofBusiness
p,I, LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code The Con o dsr's improv Lew docs no,apply
to tr owner of property who builds tr improves ensed p.and who LAWN SPR INKLER$-OVER 5(EA.) 9.00
contracts for such projects with a commdorl if licensed pursuant to
the Coarbor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO
lm .
❑ laexempt under sea .B.&PC.for this WATER HEATER W/VENT
reason 4.00
Date Owner 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,
or it certificate of Worker;Contpensution Insurance,or a certified ZONING ENG.SITE NO.
copy there I 1 e- 3800,Lab.0 I
Policy N tmpany
❑ Certified copy Is hereby furnished.
Z Z Cetlifi I fc��yl, sprdyyI Jb-i FIRE SPRINK ENERGY T-29
FO ApphcanIt (-T"S- (f� MISC.- REFER TO ORD. Y [:] NY [:] N[:]
CC T CERTIFICATE OI'1?KIiM PTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL O (This section need not he completed if the permit is for one ITOTAL Y❑ N❑ Y ❑ NI
Z) 2 hundred dollars IS 100)or less
U O 1 certify that in the performmnce of the work for which this per-
LL U mit is issued,I Shull not employ any person in any"tanner so as 1O
O w become subject to the Worksus Compensation Laws of California. -
a
Date-Applicant ALTER OR ADD TO MECH. q,pp BUILDING
>_ W NOTICE TO APPLICANT: If,after making this Certificate OFLT.
? entption,you should become subject to the Workers'Compensn,ion APPLIANCE 4.
prPLAN CHECK
provisions of the Labor Code, you must fohwith rtcomply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10 .) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 F SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUC 1 2.00
,he perlmorance of the work for which this permit is issued(Sec. MICROFILM
3097,nder's .am � HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UNIT 100,000 BA
ELECTRIC
I certify that I have read this application and state Ihanhe above VENTILATION FAN (SINGLE) 3.00
infnnnation n coarct. 1 s rel to comply with all oily arid my PLUMBING
ordinances and state laws relating to building construction, and BOILER H,P.or 100,0000.T.U.1 4.00
hereby authorise representatives of this city to enter union fire
above mentioned property for inspection purposes. BOILER-COMP (Over 100.000 OTU(SEE FEE SCH. MECHANICAL /001-0
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs' and expense,which CONST.TAX
may in any way uceme against said City in conseq"mteC of the PERMIT ISSUANCE 3.00
g tg of`ills p n t ME ONT LIC.NO. MECH.
_(� TOTAL -Zj TOTAL
4 Ha
Signature of APPI cmll/Conton, D to ��S
OFFICE COPY