3122 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES — USE BALLPOINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION PER
APPLICATION $l PERMIT 1 //_
-� AUILOWG - 1 Z Y
AEGESS
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
'
OWNER S PLAN CHECK VALIDATION
' NAME
DTY. ELECTRIC PERMIT FEE
NIr ONES
rcinr.+e"AcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
RA
LIC.No. LIGHTING FIXTURES - 5.00/1.00
CO
.ADDNTRA RESS ons PPLIANCES-'RESIDENTIAL 4.00
-
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS ______g_.00 PLAN CHECK FEE P.C.NO.
ENGINEER -
LIC.No.. SIGNS TRANS. 3.00
ARCHORENG'. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. - 15.00 -
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
" SERVICE CHANGE - 10.00
o a LICENSED CONTRACTORS DECLARATION
¢ Ea w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
- N a w (Commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H x Professions Code,and my license is in full force and effect ❑ ❑ ❑
oi L w 'License Class Lia.Number
H m H J Data Contractor
a se s -". BUILDING PERMIT
¢ ¢ a - OWNER-BUILDER D17CLARATION -
o s ° - MISC.— REFER TO ORD INFORMATION
"w g y. 1 hereby affirm that 1 am exempt from the Contractor's License
VALUATION $/FT:
FU0 < Law for the following reason.(Sec.7031.5,Businessund Professions 'PERMIT ISSUANCE 6.00
Code:Any City or County which requires a permit to construct,alter;
¢ ¢¢ improve, or repair any stfucWre,prior to its issuance,also. ELEC.CONTR. LIC.NO. ELEC.
u w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractors License Gas
HZQ Law(Chapler 9(commencingwith Section 70001of Division3ol the (F
4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exempllon.Any violation of Section 7031.5 STORIES TYPE NSTR.
ai — by any applicant for a permit subjects the applicant too civil penalty gLTER-DRAIN'& VENT-WATER (EA.) 4.00
of not more than five hundred dollars IS5O0).)',
❑ 19 as owner Of the property,or my employees with wugcs as BACKFLOW PROTECT. DEVICE. 2.00 - - OCC:GROUP RES.UNITS
their sole compenmtion,wilLdo the work,and the structure is not ,
intended or offered for suledSec. 7044, Rusincse and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00 -
Code:The Contractor's License[.use does not apply to an owner(it' - y
properly who builds or improves thereon,and who does such work FIXTURES-PER-TRAP 4.00 SO,PT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided Ihat such....
inept,are not Intended or offered for sole.If,however,the handing GAS-EA.SYSTEM,-11NC.40UTLETS 4,00
or improvement is sold within one year of completion, the owner.builder will have the burden of proving that he did not build or int- GAS:EA.SYSTEM-'OVER 4 (EA.) '1,00 BUILDING USE
- prove for purpose of sale,), INDUSTRIAL WASTE INTER. 0 RES IND CDN PB Diner
. ElI,as owner of the properly,am exclusively contracling with E] -
licensed contractors to construct the project IS". 7044,Business LAWN SPRINKLERS-1 INC 5 V.B ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply -
toanownerofpropeflywhohoilds or improves thereon,and who LAWN SPRINKLERS-OVER ( ) 1.00
contracts for such projects with a conlractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200 /S.0 TRACT NO, PARCEL NO.
❑ 1 a exempt under See P ,fur thisON
reason WATER HEATER W/VENT - ' 4.00
/ — ,
Date n WATER SYSTEM IIID - ACC.DATE ACC.FILE NO,
WORKERS'COMPENSA'F1ON DECLARATION WATER TREATING EQUIP. 14.00
I 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 certified .
copy thereof(Sec.3800,Iab.C.).
Policy Nn. Company
Q 0 Certified Copy is herebyto...ished. - FIRE GPRINK ENERGY T44
Z.Z 0 Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant - Y ❑ N� Y ❑ N�
~ in PERMIT ISSUANCE 6,00
LU GERTII°1CATIi E IiA'iION INS PROMWORK IiRS' FLOOD ZONE A.L.u.C.
W � COMPENSATION INSURANCE PILO.CONTR. -. LIF NO. pLG. .
CL O (This section need,not be complete) if the Permit is for one TOTAL Q`�� Y N� Y N�
D Z hundred dollars($100)or less.) -
U O 1 certify that in the performance of the work for which,this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1— mit is issued,1 shall not employ any person in any manner so as to
O Wbecome subject to the Workers'Compensation Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate of,Ex
F Z 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 provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 '
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.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(OV ER 100,000 B.T.U.)7.50
Lender's Address• ' ELECTRIC
I certify that I hive read this application and state that the above VENTILATION'FAN (SINGLE) 3.00 `- Uy
information is correct. I agree to comply with all City mal county BOILER H.P.or lGO,000B.T.U.) 4.00 ' PLUMBING ( Q
ordinances unit slate laws relating to building Construction, and
hereby:uuthoriee.representatives of this city to enter upnmthe BOILER-COMP (Over 100,0006TUI SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save. indemnify and keep bnrnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE" 3.00 CONST.TAX
may in any way,accrue against said City in consequence,of the -
" gr ng this pennll. MECH,CONT. 1 LIC.NO. MECH. '
—g2 OTAL TOTAL
Si noturo of icon 'o tractor Uutc ..
. - 'OFFICE COPY