0216 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0 216
ADOR ss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S t PLAN CHECK VALIDATION
/y���. TY. a' 'ELECTRIC PERMIT =FEE.a
ON I -%
ACTOROUTLETS-SWITCHES-RECEP 5.00/1.00
uO ND. / LIGHTING FIXTURES 5.00/1.00
NRESS. ` • PPLIANCES-RESIDENTIAL 4.00
DORS/S3
f/ PHONE PANELS 5.00 DATE OF APPLICATION
' R
ARCHECT SIGNS 6,00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
aooniDSS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION '
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS ]}v - SEE FEE SCHCH.
ADDRESS
SERVICE CHANGE 10.00
w
'02 LICENSED CONTRACTORS DECLARATION
< U spa I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
4"' (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
� i Profession,Code,and my license is in full f f .'5
Z 0 u'"s- License lass Lic.Number _ ❑ ❑ ❑ ❑
2 2: 1., 0 Date Conlnxto
a Y _ "BUILDING PERMIT?ia'j(i^
e Ic w u OWNER-BUILDER :uip; :L71NFORMATIONa,°ti5
WA H I hereby affirm that I am exem 1 from the Contractors . MISC.- fl EFER TO ORD
oa Law for the following reason. 7031.5•Business and Prof ssiuns PERMIT ISSUANCE 600 VALUATION E/FT:
tLL0J Code:Any city or county which requires a permit to constru .alter, /
C5¢ improve,demolish,or repair any structure,prior to its issu ce,also ELEC.CONTR. LIC.N0. ELEC. W Q
n y O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$se he is licensed pursuant to the provisions of the Contractor's License s
ri>
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe c - J�-aµ r i'11' '' •...A. r *+rni I. )"`=f
a Business and Professions Code)or that he is exempt therefrom and aTY PLUMBING PERMIT ks a FEE,;"
¢rQ the basis for the alleged exemption.Any violation ofSection 70315 _ - .`." ds e'. ° .�+u�`P•�'t;�rv' r.- Y• STORIES VPE CONSTR.
by any applicant for a permit subjects the applicanttoa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S5001.1:
❑ I,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 do the work,and the structure is not
intended or offered for sale(Sec. 7004. 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 FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS -11NC.40UTLETS 4.00
mems are not intended or offered for sale.If,however.the building
or builder
will have
is sold within one year of completion.the owner- GAS•EA.SYSTEM•OVER 4(EA.) 1.00 ButlOwN USE
builder will have the burden of proving that he did not build or im- RES IND CON P9 Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,he exclusively. 7044,tBu with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to anowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractosls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compression Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Z p Applicant •- Y❑ N❑ v ❑ N❑
CC LO CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU ? COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
D. O (This section need not be completed if the permit is for one I TOTAL V❑ BIC] V C] N❑
Z hundred dollars(S 100)or less.) it .�y'st rr t., ft11"1.Y.*f1 {` ,j"�;p t Ak•. t1p4.+ Th'e L+9x m7+,;�` "'^^•+•' tt°jL�v-
V O I certifythat in the performance of the work for which This er s s ..(FEE SUMMARY+
p p QTY ' a MECHANICAL,PERMIT;i4',,' y FEE:3 s;kjeL.. ... cYB0,4a;-'•fe
F mit is issued,1 shall not employ any person in any manner an as to p)4x t -s•r yr i-c y I I •
LL U become subject to the Worken Compensation Laws of Califomla. - - '„rb-- - •G-
y Dau ApplicantALTER OR ADD TO MECH. 4.00 A BUILDING
} In 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 provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AWC.F.lM 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE fS�
I hereby affirm that then is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OV ER 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 BOILEA-CON?13 H.P.or 100,0008.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construction. and
Hereby authorize representatives city eenter upon the
BOILER-COMP(Over 100,000 BTU(SEE PEE BCH. 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,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gmntingoflhts permit. MECH.CONT. LIC.NO. MOTAL
";TOTAL,,
Signature ol'Applicant/Cnntraelur Date
OFFICE COPY