8452 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEPJ ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NU IBE
BDuoINc APPLICATION & PERMIT
AOOREss 8 4 5 2
�d� 70 N 'DV BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 8452
rlr
OWNER'S
OWNS / ,/� �1 PLAN CHECK VALIDATION
• VIO N • I7NQ ELECTRIC PERMIT FEE
PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
cONTRACLIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDR ESS TOR'S APPLIANCES-RESIDENTIAL 4,00
PHONE PANELS 10.00 DATE OF APPLICATION
ORRCHITECi PANELS IOV ER 200 AMP; 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LOC.NO. SIGNS TRANS. 3.00
ARCH,OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
nv TEMP. METER OR POLE INS. 20.00
APUCANTS
ADDRESS _MOTORS gSEE FEE SCH.
SERVICECHAN ` —30:90 0-n
Foo LICENSED CONTRACTORS DECLARATION TEMP.P9W AfAPP Te n , 30,00
a v w I hereby affirm that I am licensed under provisions of Cha ter 9 " /- :J L.J J
¢ p ISSUANCE DATE
H G Iconunencing with Section 7000)of Division 3 of the Business and BLDG. E
O z Professions Coda e
and my license is in full force and effect s•i, r / ❑ LECT. PLG. MECH.
�\ ❑ ❑
Z,o m — License Class sc.Numbers I 01
F y L j Date Contractor
¢ a a ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
' o>" MIS REFER TOO INFORMATION
w 3 LL I- 1 hereby affirm that I am exempt from 0se Contractor's License
a, u O,, Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 5�0 VALUATION $/FT.
Code'.Any city or county which requires a permit to construct,alter,
¢ ¢< 2O improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTH. LIC.NO. ELEC.
sa D¢ requires the applicant for such permit to file a signed statement that TOTAL
6 w m u he is licensed pursuant to the provisions of the Contractor's License �i PERMIT TO
r z m Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
s i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE r
M 1 S the basis far the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 _ by any applicant fora permit subjects $500).applicant toacivilpenalry ALTER-DRAIN -WATER (EA.) 5.00
of not marc than five hundred dollars(5500).):
❑ 1,as owner of the Property,or my employees with wages us BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ 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. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Buell projects with a contractor(s)licensed pursuer 10 SEWER-SANITARY-STORM EA.200ft/10.00
the Canty tors License Law. TRACT NO. PARCEL NO.
❑ I a s •x<mpt Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason_
Owner_ Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATIA DECLARATION WATER TREATING EQUIP. 5.00
1 hereby mflml that I have a ecrtllicute of consent to self-msum, $ONING ENG.SITE NO.
or a certificate Of Workers'Compensation Insurance,or a certified
copy the roof(Sec.3800,Iab.C.).
Policy No. Company
O ❑ Cetlifedcopykil ere by f.,culmd. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is Filed with the city inspection division. MISC.- REFER TO ORD.
F O Applicant V ❑ N❑ V ❑ N❑
LU y CERTIFICATE017 EXEMPTION' FROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD zorvE A.L.U.C.
W > COMPENSlION
INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL Y❑ No , Y ❑ N❑
D Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per. OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.1 shall not employ any person in any runner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
Is. Date Applicant ALTER OR ADD TO MECH. 5.00
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? cmption,you should become subject to the Workers'Comperecomn APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code. you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ci .C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building const rucl ion, and
hereby authorlee mpresentatives of this city to enter upon the g01 LER-COMP IOon 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpos
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ma n any way accrue gainst said City in consequence of the
gr t gOft yt�I MECH.CONT. LIC.NO. MECH.
( 1iic ,�ra to TOTAL TOTAL
Signature of Applicant antra r Date
OFFICE COPY