3414 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON P ER
BUILDING APPLICATION & PERMIT n
'1/ no ss ` Da �� ' BUILDING- ELECTRICAL-PLUMBING-MECHANICAL T T
//�, OWNER'S I PLAN CHECK VALIDATION
N"n OTY. ELECTRIC PERMIT FEE
JvRONE`
CON ACTOR ,j OUTLETS-SWITCHES-RECEP 5.00/1,00 O•�
NA
4T CQn/,p11C.NO f9.FI79LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
DREss
`S` C PHDNE PANELS 5,00 DATE OF APPLICATION
ARCHI EC SIGNS 8.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
TIP EMP. METER OR POLE INS. 15.00
APPLICANT'$ MOTORS SEE FEE SCH.
ADORE55
SERVICE CHANGE 10.00
o ¢ i /
'02 LICt NSEU CONTRACTORS DECLARATION rJ//
G v w I Itureby affirm that I and li caused under provisions of Chapter 9 ISSUANCE GATE
(in ommencing with Section 7000)of Division 3 of the Business and
SLOG. ELECT. PLG. MECH
D i Professions Code d y license iz in full fO � �]iqV__+/f ❑ ❑ IC{
o w - Lice n Cass Li<.Numbe a ICI
C,
Date y' Contnemr
H
x < BUILDING PERMIT
_ ¢ OWNIiR-BUILUICR DECLARA TION INFORMATION
o A I herebyaffirm that 1 am exempt from the Contractor's Lie MISC.- REFER TO OflD
K
p VALUATION
La w o a Law for the following reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit io conMritl,alter.
is Improve.demolish,or repair any s ructure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. lem
- D¢ requires the applicant for such permit to file a signed statement that TOTAL p�0?• PERMIT TO
wm he is licensed pursuant H,the provisions or the Contractor's License
F z i
Law(Chapter 9(commencingwitll Section 7000)of Division 3 of the
4 Business and Professions Code)or that he is exempt tiferefrom and QTY. PLUMBING PERMIT FEE
f x O STORIES TYPE CONSTR.
¢ the basis for the alleged exemption.Any violation of Section 7031.5
IL ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not inorV than if,,hundred dollars(55001.)'.
❑ I,as owner of the property,mr my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 ooc.caouP RES.UNITS sole compensation,will do the work,and the structure is not
intended or offered for sale ISec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's Lieense Law dues net apply m an owner of
property who builds or improves thereon,and who does such work F IXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve'
Gents are not intended or offered for sale.If.however,the budding GAS
or
SYSTEM-1 INCA OUTLETS 4.00
or inprrovemevt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- REs IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ Cl ❑ ❑ ❑
licensed cnntmcmD to construct Thu project ISec.7044.Bmsiness LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO,
sio
anProfLicenses Code:'I'he Contractor's License Law docs not apply '
dto an owner of property who builds or improves thereo t.and who LAWN SPRINKLERS OVER 5 1EA.1 1.00
contracts for such projects with n contmetorts)licensed purstunt to
SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Ism exempt unJer See .B.&P.C.Iia this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.OATE ACG FILE NO.
wORKFRs'COf.U°ENSA'I'[ON DECLARA'I ION WATER TREATING EQUIP, 4.00
I hereby affirm that 1 have a certificate ol'wnsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thcr"of l Sec.3800,11
Policy Nn. Company JI
❑ ertifieJc y'is rete
urn a FIRE SPR INK ENERGY T 24
7/ Certifin p A w anti division. MISC.- REFER TO ORD.
Applicant _ Y(] N❑ Y ❑ NE]2
F' yPERMIT ISSUANCE 6.00 FLOODZONE A.L.uc.
3: CERTIFICATE OF EXEMPTION FROM W RKIiRS'
LU CO\iPI:NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL ❑ CII secc{{'Do need not be completed if the permit is for one TOTAL v❑ N❑ v❑ N❑
� Z hundred dollars1S100)or less.)
U Q 1 certify that in to performance of We work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any Intoner so as to
Ow become subject to the workers'Compensation Laws of Calil'urnia. ✓ BUILDING
a
Date Applicant ALTER OR ADD TO MECH. 4.00
} to NOTICE TO APPLICANT': If,after making this Certificate of lex-
. ? emsyou should become subject to the workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions the Labor Code, you must forthwith comply with FEE
U
such provisions
ns or this Permit shall be Jccitevo
ncJ revokcJ, AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance Of the work for which this permit is issued ISec. MICROFILM
3097,Civ.C.1. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. information is correeL I agree to comply with all city and county BOILER-COMPI3 H.P.or 100,000 B.T.U.1 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby aunlonre representatives of this city to enter upon me BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL 0 ee
above-mentioned property torimpection purposes.
(We) agree to save, indemnify and k""harmless the City'of MISC.- REFER TO ORD.
Cupertino a ainst Habil' judgme ts, o s a exp nses which �I CONST.TAX
may 11 a c •sin. It a enc" of the PERMIT ISSUANCE 3.00
granlil t ITL MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL 9 `�
Ignttruc o f Applicant/Cmrtructur Date
OFFICE COPY