1400 -APPLICANT TO-FILL IN INFORMATION WITHIN RED-LINES -,USE BALD POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PE MIr E
BUILDING I APPLICATION & PERMIT n
ADDRESSBLECTRICAL-PLUMBING-MECHANICALULDING -E
o 0
OWNER'S - PLAN CHECK VALIDATION
NAME A4K-ft r KNGNE 57_1411 DTV. ELECTRIC PERMIT FEE
'I CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 13
�,9-�.E
C r'Y•'��'21CI NO ��� v LIGHTING FIXTURES 5.00/1.00
ADScioR's
DREAPPLIANCES-RESIDENTIAL 4.00
Z�/Vr�I SEI( PRONE(JJ7 �`� PANELS 5.00 DATE OF APPLICATION
ENGINEER SIGNS 6.00 PLAN CHECKFEE P.C.NO.
oR N
ENGINEER
LIC.NO. SIGNS TR Of, 3.00
AARCH OR
DDRESS ENG. - SPECIAL CWCUIT 5,00 PERMIT VALIDATION
Zlv EMP.METER FOL NS. 15.00
AMOTORS EE FEE SCH,
ADDDRESSDRESS
SERVICE CHANGE 10.00 V
w o o LICENSED CONTRACTORS DECLARATION
ri c I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F i Professions Cod d my license is in full force
oi o License
ss Lic.Number
2 w r j Date ' Contractor
BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
c s v INFORMATION
m ;LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o a Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.
H - w g .PERMIT ISSUANCE
Code:Any city or county which requires a permit loconstrucLaller. 6.00 Oto
also ELEC.CONTR. LIF NO.
Q Q ¢ ,O improve,demolish,Or repair any omit tnfe,prior to its statement that EOTA V e0
i y c a. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m in he is licensed pursuant to the provisions of the Contractor's License _ w �:
Law(Chapter 9(commencing with Section 7000)af Division3ofthe 1 J/�J//7/QjJ`
Y 4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT - FEE
ec H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
by Say applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(55000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE- 2,00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves(hereon,and who does such work FIXTURES-PER TRAP 4.00 SO.vi.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
ments enot inth In oor wn
eeor sale.Ii,however,ded that suhebwlding GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
of 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 im- . WILDING USE
prove for purpose ofsale.). RES O er
CON PB Oih' Q dD
❑ I,as owner of jlte properly,am exclusively conlructi ng with INDUSTRIAL WASTE INTER. 20.00 If
licensed contractors 1. construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/6.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 4.00
son
Date Owner WATER SYSTEM 4.00 ACC.DATE - ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a Iterlified ZONING ENG.SITE NO.
eopyLan.C.)ay��r �GL7�lN v/4�
colic mapany
C �fs�
Q ❑ Certified copy is hereby furnish
Z Z Cetlifie ,c d w h city iny+ycl�io yyj FIRE SPRINK ENERGY T-24
�+ ^nJ�'Y�}� MISC.- REFER TO ORD.
p Applicant^=-�� !S�_� Y 0 NO v 0 NO
� 9 CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.C.u.c.
LU > .COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This section need not be completed it' (tic permit is fnr one TOTAL v � Y 0 . NEI Y 0 NO.
Z) 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 F mit is issued,I shall not employ any person in any manner w as to
O W become subject to the Workers Compensation Laws of California.
y Date Applicant f liALTER OR ADD TO MECH. 4,00 BUILDING T� J
} to NOTICE TO APPLICANT: If,after making this Certificate ox-
� ? 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
C.7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AMC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMICFEE' SO
I hereby affirm that there is a on traction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work far hi this permit is issued(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name (
N
HEATING UNIT OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read thisap Iication and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county PLUMBING �,J
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.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.- REFER TO ORD.
Cupertino against liabilities,pi gme costs and expenses wllich PERMIT ISSUANCE 3.00 CONST.TAX
may in any y accrue ogain sa' Cty in consequence of the
gr is8 fl p I f4-� MECH.CONT. LIC.NO. MECH.
(L TOTAL. TOTAL
igunturn D1 Applman[/Conlrnctor Date
OFFICE COPY r