6034 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION ON , - T PERMITNUMBER .
+/ BUILDING APPLICATION & PERMIT .
ADD.ES
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6034
PLA ALIOATION
OTV• ELECTRIC„PERMIT FEE qpp pp
NO.... oRs UTLETS-SWITCHES-RECEP 5.00/1.00 SEP l D 1 94
' LIC.No.M16 LIGHTING FIXTURES 5.00/1.00 rk
G••/�' CONTRACTORS CiTy�of Capel Linos ..
;8Ess 1 APPLIANCES-;RESIDENTIAL 4.00
L riPHONE ,PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 ` PLAN CHECK FEE P.C.NO,
on '
jE NGINEER - - '
' LIC.No. 'SIGNS TRANS. 3.00 r I
AARCH. R
DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
' ZIP TEMP.METER OR POLE INS. 15.00
APPO SA
ADDRESS AMOTORS - SEE FEE SCH.
I ,
't - SERVICE CHANGE ' •10.00
LICENSED CONTRACTORS DECLARATION. s
< u 1 Ilerehy affirm that I am licensed under provisioiis of Chapterv9ISSUANCE GATE
ya fico....a Being with Section 7000)of Division 3'of the Business and,
.a BL C. ELECT. PLG. MECH.
N
Z.
PlL,,2TGDa Codi and m license Is In tull'I'oo:e and effect. ,
Z.
ORm- I-jocose Glasse6n Number l�$_l Z ❑ ❑ - ❑
o m t w Ualc_q=� Contractor ll[(-'$ R =Ut -
a BUILDING PERMIT
rt ¢ OWNER-BUILDFR DFCLARATION
a on.u`. - ' ISC.- REFER TO ORD INFORMATION':'.
X I hereby affirm Riot I am exempDfronl,Dm Contrnctor'S License
3'LL rn VALUATION 'S/FT.
F u O J Law I'or the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
mvs. Code:Anycity orcounty which requires a permit to construct,alter,
2 ¢ a p _ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
u DLL requires the applicant for such permit to file a signed statement that TOTAL
o
A. w m m he is licensed pursuant to the provisions of the Contractor's License PERMIT
FZ >-
Law(Chapter 9 commencing with Section 7000)ofDivieion3 ofthe '-
F i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M H o the basis for the alleged exemption.Any violation of Secl ion 7031.5 STqi IES TCONSTR.
a, by any applicant For a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollurs($500).): -
Cl 07
I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.•DEVICE 2.00 C GROUP / ITStheir sole compensation,will do the work,and the structure is not
intended or offer.! for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 -
Code:The Contractors 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 'FT,FLOOR; TOTALACREAGE
•• himself or through his own employees,provided that such improve-
meals are not intended or offered for sale.U',however,the budding GAS
Or
4.00
or aloo0vememt is sold within one year of completion,the owner- GAS.-EA.SYSTEM-OVER 4-(EA.) 1.00 BUILDING USE
builder will havo the burden of proving that he did not build or Im-
prove for purpose ofsale,). INDUSTRIAL WASTE INTER. 2000 RES IND CON PB' Other
.
❑ I,as owner of 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,
Ali"
Professions Code:The Contractor's License Law does not apply I„
to an owner o1property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
conitaCtthe Contract wchprnjecLwith acontractnnsl licensed pursuant In SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
the Contractor's h Projects
Law.
❑ Iamexemptunder Sec. ,B.&P.C.forthis WATER HEATER W/VENT4.00
reason
Owner - Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPBNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby Offen that I have a certificate ofconsent to selNnsure,
j ora certificate of Workers'Compensation Insurance,or a certified ZONING' ENG.SITE NO.
copy therS5o�I(So,3800,Lat,1:.)eC �1 np ll.'
Policy No(pj/ROLlCmqumy_ t FyN)Z' !
O' ❑ Certified rpy is hereby furnished.
Z Z - a copy is f •d w'll the cit inspection division. FIRESPRINK ENERGY T 24
(] Applicant MISC.- REFER TO ORD. V L] IN Y E] No
12 " .IiRTII'1 CATI:0171; EMPTION FROM ORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE a.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. .I LIC.NO. PLG.
CLO ('I'his section need not he complcmJ il:,the.permit is I'ar ;no TOTAL ' Y❑'/1 N[] Y ,❑ At
Z hundred dollars IS 100)or loss.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT ..,FEE, FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so us to
U- hvenme vehjcel to Lite Workers'Compensation Laws of California.
O i Date - Applicant ALTER OR ADD TO MECH. 4.00 "BUILDING
'IC
>- rn NO'Ir TO APPLICANT: If,after Taking this Certificate of Ek-
F ? cmplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
prisions of the Labor Code, you must forthwith comply with
U sucov11 provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10DOO11F.M) 3.00 FEE
CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER 10DW C-F.M.) 6.00 SEISMIC FEE P�
I hereby affirm that there is a construction lendiAg 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,UN IT(OVER 100,000 B.T.U,)7.50
Lender's Address ELECTRIC. "
I certify.that I 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 construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 4.00
hereby authorise representatives of this city,to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCHMECHANICAL
above-mentioned pruperty for inspection purposus. _ - -
(We) agree to save, indemnify and keep harmless line City of MISC.- REFER TO ORD
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.001 CONST.TAX
may any way accrue.n must said City in consequence of the
grant'Ig of this In niiL MECH.CONT, LIC.NO, MECH. / �0
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rit_�
b TOTAL TOTAL
1„X1 ignahrreof Appli nt/Contractor I ate D
OFFICE COPY