3448 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
lo4 >•BU I LDING PROJECT IDENTIFICATION ER rNUMBER
BUILDING APPLICATION & PERMIT 3448
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER SI PLAN CHECK VALIDATION
NAME TV. ELECTRIC PERMIT FEE
4446-44
c NT ACT Rs OUTLETS-SWITCHES-RECEP 5,00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 5.00/1.00
C.ONTR TORS
ADDR s - APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER LIC.
c.No. SIGNS TRANS.
ARC H.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPUCANTS MOTORS SEE FEE SCH.
AooREss
SERVICE CHANGE 10.00
w
00 LICENSED CONTRACTORS DI?CLARATION
II:o U I he.L•h,aff,n, that I in IiecesEd under pm inions of Chapter 9 ISSUANCE DATE
hz n (commencing with Section 7000)of Division 3sof the Business and BLDG. ELECT- PLG. MECH.
r w i Professions Code,and my license is in full force ind effect. ❑ ❑ ❑
z o m License I Lic.Number}/�///
H Date �� Con l ractor_
a Y sBUILDING PERMIT
m ¢ OWNER-BUILDER DI-CLARA' ON INFORMATION
Ao MISC.- REFER TO ORD
La 3 LL R I hereby affirm that I um exempt from the Cnnvuctur',Li, VALUATION $/FT.
F u o a Law for the following reason.(Se<.]031.5,Business anJ Professions PERMIT ISSUANCE 6.00
Code:Any city or county which reyuiresa permit toconstrucLaltec
Ftic O improve,demolish,n!repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. Of?'0
LED.
C urequires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
rrei Law Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
O STORIES TYPE CONSTR.
the basis for the alleged exemption.Any violation of Section 7031.5
by any applicant fora permit objects the applicant to a civil penalty. ALTER-DRAIN -WATER (EA.) 4.00
RI out more thou five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 MOR-OUP 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,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of e
property who builds or improves thereon.and who docs such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own em Ployees.providN that such improve-
mems are not imcaded nr offered fOra.IC.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 UI GING USE
builder will have the burden of proving that he did not build or im-
ve for purpose of all.). RES IND CON PB Otter
P{V pose a INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ Q
len d as owner of the property,he exclusively contracting with
Incensed contractors to construct the project(See, 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 AS EGSORS PARCEL G.
andProfessions Code:The Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS OVER 5 IEA.) 1.00
contracts for such projects with a contmetods)licensed pursuant to
the Contractor's License Law. p SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ium exempt under See. WATER HEATER W/VENT 4.00
reason
Uate� Ownc WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
RIRR1:TRII DEGI-A Ra I'ION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING
or a certificate of Workers'Com Pensoli m In yamn.e,or a ,rtili,d ENG.SITE NO,
copy thereof(Sec.3800,LabC.).
Policy No. Company
O ❑ CcrlilicJ CoPY'ix hereby tarnished, FIRESPRINK ENERGYT24
Z z ❑ Certified copy is fled with the city respectful division. - REFER TO ORD.MISC.
F 0 Applicant V OO NE V � IN El
Cc: w CERTIFICA'1'1:OI'li x I:MPl'ION I'RDN WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE a.L.U.C.
111 >_ COMP14NSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O ("this Section need not be completed if the permit Is for 011e TOTAL Y F-1 NE] Y E] NE]
Z) z hundred dollars IS too)ur less.)
U Q 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,1 shall not employ any Person in anymanner so as to
O w beconm subject to the Workers'Compensation Laws of BUILDING
Calitorniu. ufl
Dale Applic.nl ALTER OR ADD TO MECH. 4,00
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F, Z emptiml,you should hecnme subject m the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
P,0
visions 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)000C.F.M.) 3.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Namey. HEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that l haveread this up plication and state that the ub...L. VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and CountyBOILER-COMP(3 H.P.or 100,000 B.T.U) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby aulhori<o Hcprc,CFwtivcs of this city to voter upon life BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
.hove-mentioned properly for inspection Purposes.
(we) agree IN save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino iguinst liabilities,judgments, costs 'and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
ir�' M
y accrue against said City' in consequence ol'tire
Ien»it. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Ii n_t ootramm )- c - -
OFFICE COPY