1472 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLYtIUM
ER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT 1472
1), BUILDING
ADOREss ! LDING-ELECTRICAL-PLUMBING-MECHANICAL
.�
;.,w•. {"'+^ " I" `�+,;�;�'• PLAN CHECK VALIDATION
OWN R'$
7s NAME I, s -ELECTRIC PERMIT `FEE _
Y PHONE T ' ,
ONTRADTOR's UTLETS-SWITCHES•RECEP 8.00/1.00
NAME
o.
LIGHTING FIXTURES 5.00/1.00
�g
roNTRActoR's � PPLIANCES•RESIDE NTIAL 4.00
ADDRESS PANELS
NON 5.00 DATE OF APPLICATION
ARC ECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER SIGNS TRANS. 3.00
LIC.NO. PERMIT VALIDATION
ARCH.OR ENG. SPECIALCIRCUIT 5.00
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
W o o LICENSED CONTRACTORS DECLARATION
au u I hereby affirm that I am licensed under vrovisions of Chapter 9 ISSUANCE DATE
w< i Icommencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
o z Professions Coda d my license is in full force d effe
' 0. - License lav Lic.Number
gy=° Datatractor �ti'� BUILDINO,P.ERMIT"z v"
¢ Wa �i`^OOWNER-BUILDER DECLARATION a� REFER TO INFORM/1TION=j '?
o u MISC.-
mS e N I hereby affirm that 1 am exempt from the Contractor's License VALUATION SIFT.
w o a Law for the fOOowing reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 Q a�'
r- 04 LI Code:Any city or county which requires a permit to construct,aller, ELEQCONTR. LIG.NO.
ca <C improve,demolish,or repair any structure.prior to its issuance,also ELEC. W v
-o LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w8 u, he is licensed pursuant to the provisions of the Contractor's License Q
ww i Law(Chapler 9(commencingwith Section 7000)ofDivision 3 of the f:.qs_: i °�",fr'v S L' �1n rL FE�1) RCi.CCO�
i D Business and Professions Codel ar that he is exempt therefrom and CITY. 'PLUMBING P,ERMIT� a s t s
¢ r $ the basis for the alleged exemption.Any violation ofSection 7031.5 et4vv` '.-.:•„1'K`ssct.A'.i`.-.'_a.- a+-.=s " fiI`"= STORIES
TYPE CONgrR.
byanyapplicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).1:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR OND. 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-EA.SYSTEM-i INC UTL 4.00
.menta are not intended or offered for sale.If.however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OV E A.) BUILDING USE
builder will have the burden of proving that he did not build or am- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE IN R. 20. ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
I ilk-
licensed contractors to constructthe project(Sec. 7044,Business LAWN SPRINKLERS- V.B. 5.00 ASSESSDRS PARCEL NO.
and Professions Code:The Contractor i License Law does nut apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS•OV E .) 1.00
contracts for such projects with a contractorl s)licensed pursuant to SEWER-SANITARY-STORM E .200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
are Owner WATER SYSTEM 4.00 A .OATE ACC.FILE NO.
CC
WORK ERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
`' or a certificate of Workers'Compensation Insurance,Or a certified
% copy thereof(Sec.3800,Lab.C.).rEE�,T��Jt.
Policy No. Company
O ❑ Certified c0 is hereby furnished. FIRE SPRINK ENERGY T34
Z Z ❑ Certified is filed i(b (ion division.ith (ion division. MISC.- REFER TO ORD. Y N� v ❑ No
Applicant
rn C TIFICA'fE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.G.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y N� r N[]
TOTAL
(This
(This section need not be completed if(he permit is for one
D Z hundred dollars(I 100)or less.) t" 7
l •ar a! Y 4 .w M Y�;
U O I certif that in the erformance of the work for which this per D i,. SFEE�SUMMARYyj.
y p p QTY. -s ''MECHANICAL PERMITM1„.^,� I:FEE I i r .ti�.,
LL F mil is issued,1 shall not employ any person in any manner so as to s�.i4eis'sy1 p• _;-h o - a ..'a e , A•�s
Ow become subject to the Workeri Compensation Laws of Califomsa. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
W NOTICE TO APPLICANT: If,after making[his Certificate of Ex.
} a 4.00 PLAN CHECK
Z proe si n you should become subject to the Workers'Compensation APPLIANCE
provisions io the Labor Code, you Most d revoke comply with AIR HANDLING UNIT(TO 10XOC.F.M) 3.00 FEE
(� such provisions or this permit shall be deemed revoked. ,`0
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 1,
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT ITU 100,000 B.T.U.) 4.0
3097,Civ.C.l. 0
Lender's Name HEATING UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale hat(he above VENTILATION FAN (SINGLE) 3.00 PLUMBING
• information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
ordinances and state laws relating to building construction. and
hereby authorize representatives Of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
.I Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.001CONST.TAX
may i any way accrue against said City in consequence of the ..
Stan of this perm MECH.CONT. LIG.NO. MECH.
J oTAL TOTA L'tw7
Ignature of Appllsan ontracmr Date
�� OFFICE COPY