0471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAI L POINT PEN ONLY
. BUILDING PROJECT IDENTI FICAT7T PERMIr NUMBER
BUILDINGAPPLICATION & PARO A
AO RE55 `F
BUILD-I
UILD1 NG-ELECTRICAL-PLUMBING-MECHANICAL
71
I OwNE 'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
r PHONE
•'
CONTITACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
ME
uDNo. 3086 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLI ANCES- ENTIAL 4.00
1A�omoREss
)ciI W ` \ PHONE p_ V 1 PANELS111 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 5.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER 3.60
LIC.No. SIGNS TRANS.
ARCH.OR ENG. 5.66 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP. METER OR 15.00
APPur
cArvs _ MOTORS SEE FEE SCH.
k /0 V
SERVICE CHANGE 10.00
oaz
Hoo LICENSED CONTRACTORS DECLARATION
BE v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y z N (commencing with Section 70001 of Division 3 of the Business and a G. ELECT, PLG. MECH.
F y z
z Professions Cps_15J,apd my license Is in full for a and r eel. ❑
z O w - License Class Lic.Number. b ❑ ❑
o H Date Contractor BUILDING PERMIT
BE w u 2 -aOW'NIi R-BUILDER UIiCLA RATIOM1' INFORMATION
w3 u y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uoj Law for the fol lowing reason.(See.7031.5,Businessxnd Professions VALUATION S/FT.
H _ PERMIT ISSUANCE 6.00 p/s
Code:Ankeny or county which reywnsa permit to construct,alter. J
se 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 T requires the applicant for such permit 10 fill'a signed statement that TOTAL PERMIT TO
w$ he is licensed 9(copursuant to tha%ith Sime of the Contractors License /jJ�y,�„t/ �jd2bif11
H z i Law fChapter9(commencing with Section 70001o(Uivision3of the /��L. �L�666 I�V/��g�fl/�IIYY
- a Business and Profusions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
SE E i
I- o the basis for the alleged exemption.Any violation of Section 7031.5
a ; m by any applicant for a permit subjects the applicant toacivil penally gLTER-DRAIN Be VENT-WATER (EA.) 4.00
of not more than five hundred dollars fS500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
(heir sole compensation,will do the work.and the structure is not
intended ar offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds Or heproves thereon,and Who does Such work FIXTURES-PER TRAP 4.66 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- GAS-EA.SYSTEM-11NC.40UTLET54,00
Herds are not intended oroffervid fur sale.If,however,the building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BWLDmNG USE
builder will have the burden of proving that he did not build or Ban- RES IND CON Pe Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El El 11 11 1:1❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code:The Contractor's License Low does not apply 1
' to an owner of property who builds or improves thereon
.and who LAWN SPRIN KLERS-OV ER 51EA.1 1.00
contracts for such projects witha contructunst licensed pursuant to SEWER-SANITARY-STORM EA.2001t/8.00 TRACT No. PARCEL No.
the Contractor's License Law.
❑ 1 am exempt mrdersec. .B.&1'.C.for Ibis WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORKrRS'COMPISNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG,SITE NO,
or a certificate of Workcrs'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Cmn piny
Q ❑ rIm p he by fu niched. FIRE SPRIIN ENERGY T.44
Z2 ❑ Cc_e--.r.�����.�po 1 wlh 'ilY inspection divisim,. MISC.- REFER TOORD. Y ❑ N❑ Y ❑ N❑
Appl'I�iun 0� is
Hy PERMIT ISSUANCE 6.00 FLooD zoNE A.L.U.C.
- CERTIFICATEOF EXEMPTION FROM WORKERS'
LU > COMITNSATION INSURANCE PLG.CONTR. LIC.No. PLG.
d0 TOTAL Y❑ N❑ Y ❑ N❑
('Phis �etidn need not be completed i(the pcnnid is for one
2 hundred d(IEars(SIDO)or less.)
U O 1 cortit'y that in the periormance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as do
0Q become subject to the Workers'Compensation Laws of Culilnrnia' BUILDING
BIDDate Applicam JALTERORADDTOMECH. 4.00
N01'I CF TO APP HCA NII If after making Ili is Ce if Ablate of 17x-
F ? emption,you should become subject to the Workers'Connpensation APPLIANCE 4.00 PLAN CHECK
provisions Of me Lahor Code. You must lirrthwith comply with FEE
U such provmons or this permit shag be,deemed revoked. AIR HANDLING UNIT(TO 10,000OF.M.) 3.00
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE S 0
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
lie per2srrrlance 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(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I ceroly that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
infonnalion is,,reel. 1 agree to comply with all city and countyPLUMBING
ordinances and sue laws relining to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.1 4.00
hereby Rdlio,l, representatives of this city do en VN upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned,un,uy for inspeeuon purpose
_ ✓ (We) agree to save, indemnify and keep harMess the City of MISC.- REFER TO ORD.
Cupertino against liabilities.judgments, costs and exponses which CONST.TAX
1
a
Sm
n tllf pany way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
• er T. MECH.CONT. LIC.NO. MECH.
- TOTAL TOTAL Zze-Ve
Signature of ApplicamlContraclor Date
OFFICE COPY