3396 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATION PRM ER
BUILDING APPLICATION & PERMIT 3396
ADDRESS
(7� IY r O BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
6 < - " ( I "I�. %q PLAN CHECK VALI DATION
OWNERS - -f -y
_ X u"ME �/A a T QTY. - °ELECTRIC PERMIT I � FEE s,
PHONE
CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00
NAM /
N t Q sec.No. 6 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS S40 OSG PPLIANCES-RESIDENTIAL 4.00
00� �a V ICQk+
PHONE.L /Q-�OC OD PANELS 5.00 GATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.no. SIGNS TRANS, 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10,00 4Y�3
W o o LICENSED CONTRACTORS DECLARATION
<u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N Ism (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z ProfessionsCqk and in lnse is in full fort an effecj.
Z O uvl- Licen Class( Lic.Number Q,II�_ ❑ ❑ C]4 H w Date - Contractor
It Y ,, NG PERMITZ,
¢ BE W ¢ OWNER-BUILDER DECLARATION "` °` If
U _.A5„n:Y-„1 RMATION�",+s''-,,y,.x-•_
o A MISC.- REFER TO ORD
m 0 N I for the
affirm ng 1 am exempt from the Contractor's License vnwrf7lory'�q 3/FT. .
Da Law for the following reason(Sec.7071.5.Business and Professions PERMIT ISSUANCE 6.00 I1�{3, x 11 IJ J
H Nw� Code:Any city or county which requires a permit to construct,alter. Rip 'D,Ir
¢ ¢ Q C improve,demolish,or repair any structure,prior to ifs issuance,also ELEC.CONTR. LIC.NO. ELEC.
0, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$A he is licensed pursuant to the provisions of the Contractor's License (!IIppF}�o
r ¢Q Law(Chapter 9(commencing with Section 7000)of Division 3 of the '1 P '�T�
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING.PERMIT
¢ ° the basis for the alleged exemption.Any violation of5ection 7031 5 ...:�.:.[K -. ..x'e-. SrORI PE CONSTR.
by any applicant for a permit subjects theapplicam(oacivil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollars 155000.1:
❑ 1,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 n not
intended or offered for sale(Sec. 7044, 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-EA.SVSTEM-11NC.40UTLETS 4,00
mems 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-OVER 4(EA.) 1.00 BUILDING USE
prove
builder f will have the ale.). ofproving that he did CID[build Or im- RES IND CON PB CORE,
prove for purpose of sale.). I NDUSTRIAL WASTE INTER. 20.00
❑ 1.d as owner of the properly,he exclusively.7044,lBu with ❑ ❑ ❑ ❑ ❑
andPed contractors to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 AS.SEssORS PARCEL No.
and Professions Code:The Contractor's License Law does not apply
to anowner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such License
cLwith acontnctonsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Co[am exempt
ptunde Law.
❑ lam exempt under Sec.-.BAP.C.for this _WATER HEATER W/VENT 4.00
reason
Date owner WATER SYSTEM 4.00 -DATE ACC.FILE N0.
WORK ERS'COMPF,NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers
Compe sari Igsurance,ora certified
copy thereof(Sec.3800,Lab.C.l
Policy No. Company
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGYT-24
Z ❑ Certif co 's filed ith city in ion division. MISC.- REFER TO ORD.
p Applicant V❑ N❑ V C] NE]
~ in PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU CERTIFICATE COMPENSATION EXEMPTION FROM WORKERS'
CL dnotacorn INSURANCE PLG.CONTR. LIC.NO. PLG, Y❑ N❑ y❑ N❑
CL O (This section need not be completed if the permit u for one TOTAL
72 hundred dollars IS 100)or len.) itu�. :I."Ikt"`t3.�+ I' vr 'yL:yyti� I^i i.4 Yt,Fi _ r+H?Jr' '+TjreT,la�yFEE'SUMMARVr�
CJ O I certify that in the performance of the work for which this ptr. CITY t, tff,.MECNANICAC PERMIT - za 9 s FaEE,l Lki.yV_,.-........,.-.a...'x2i:iI
F- Her W mit is issued, I shall not employ any person in any manner an as to p uw3 a
U become subject to the Workers'Compensation Laws of Califorma. rr°wry •"fir^-' F�'; s$--^-'`7:"td`
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING �/ ��
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex"
F ? emption,you should become subject to the Workeri 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 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNfT(OVER 10=C.FM) 5.00 SEISMIC FEE f0
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 fSec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.l. -
Lend.,',ANEED
Lender i Address HEATI NG UNIT(OV E R 100,000 B.T.U.P.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply with all oily and county PLUMBING
ordinances formatio and state laws relating to building contraction, and BOILER-COMM I3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Ower 100.000 STU)SEE FEESCH. MECHANICAL
above•mentioned property for inspection purposes.
(We) agree to save, indemnify and keepharmless the City of MISC.- REFER TO ORD.
Cupertino,again liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any y accrue against City in consequence of the
granting' apermlL MECH.CONT. LIC.NO. MECH
OTAL "'J y11!+Yd^.(Nw lye
TOTAL
ignaturc of Appl' sl/Contractor ate IT
OFFICE COPY