4587 APPLICANT TO FILL IN.INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON I
PERMIT NUMBER
O
� BUFLOR DING APPLICATION & PERMIT 4557
A 5
S .� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE
Adak
HONE
NOAMERACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
1 Llc.rvo. LIGHTING FIXTURES 5.00/1.00
\/ CONTAACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
T
ADDRESS
✓PHONE .� PANELS 5.00 DATE OF APPLICATION
ARCH
OR I ECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
sec.rvD. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 9/(
_11v 4
Woo LICENSED CONTRACTORS DECLARATION
<u U 1 hereby affirm that 1 am licensed under provisions of Chapler 9 ISSUANCE DATE
N w (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
< c ❑
r N Professions Code aaJ y icenu is in full for a e l
i o,a - License 1 ss Lie.Number ❑ ❑
mr w' Dam '� Contractor_
a x �L.i/lij� BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATIO
o s O REFER TO ORD INFORMATION
X ; I- 1 hereby affirm that I am exempt from the Contractor's License MISC.-
H VALUATION $/FT.
F U N j Law forAny
Cit Or cng ounty ouch e.regiresa perBusmit
to codProfessions PERMIT ISSUANCE 6.00
I ,A � E Code:Anymolish countywh icy structure prior toots issuance, mN
¢ ¢ ¢ O improve,demolish,or for such
anystructuretoff priorneits issuance,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for such permit to filo a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License QL v
r z >0w Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ` /y B/q/GJ
4 Business and Professions Code)or that he is exempt therefrom and T/v, PLUMBING PERMIT FEE
ac H 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ I,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 is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does uch work FIXTURES-PER TRAP 4.00 - SO.FT.FLOOR AREA TOTAL ACREAGE
40 himself or through his own employees,provided that such Intl'rove
u
menare not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-I-INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-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 El ❑ ❑
❑ I,as owner of the property,am exclusively contracting with13 1:1
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereonand who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractions)licensed pu,rsuant In
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I urn exempt under Sec. ,B.&P.C.list this WAT ER HEATER W/V 4.00
reason
Date Owner WATER SYSTEM 4.00 ACG.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATI U 4.00
1 hereby affirm that I have a certificate of consent to sclGinsure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or n certilleA
copy thereof(Scc.3800,Lab.CJ.
Policy No. Company Pity Of C"Perfinn
❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z CiCertified copy is filed with the city inspection division. REFER TO ORD.
0 Applicant MISC.- Y❑ N[3 Y ❑ N[3
CC CERTIFICATE OF EXEMPTION FROM WORK ERS' PERMIT ISSUANCE 6.00 dV FLOODZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C OD YE] N� Y� NC]
(This section need not be completed if the permil is for one TOTAL
:) Z hundred dollars($100)or less.)
L) 0 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
UL I- mit is issued,I shall not employ any person in any manner so as to
O i D 0lnt-SubjEc`t Wporkers'C prix ensglion La fC liforn' .
Dam J leant-L--(Y_g%-S' BUILDING
} to NOT TO APPLICANT: If,after making this Certificate of C . ALTER OR ADD TO MECH. 4.00
F. emption,you should become subject to the Workers'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 ITO 10SMC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency tin 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 Name H EATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n curate. 1 agree to comply with u11 city and c0uoty PLUMBING
iordinancesnformation
and stmt laws relating to building l city anlion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby antim ire representatives of this city toenter upon the BOILER-COMP (Over 100,000 BTU)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.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
graNin of this per iI. MECH.CONT. . LIC.NO. MECH.
�,E./ TOTAL TOTAL
$TTggnmure of pphcanl/Contract ' Date
OFFICE COPY