4775 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
' SL{LDINc APPLICATION & PERMIT 47
. aoDRgss I J
,o2�..SijS a9U BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 75
"OWNER'S PLAN CHECK VALIDATION
NAME
DTV. ELECTRIC PERMIT FEE
E PHONE
CONERacToas 14*32-3 OUTLETS-SWITCHES-RECEP 5.00/1.00
AC LIC.N-116101111%. LIGHTING FIXTURES 5.00/1.00
x� nooeeSS TOR's PPLIANCES-RESIDENTIAL 4.00
! �S a4k /at PHONE(.FprI13 PANELS 5.00 DATE OF APPLICATION -
ADRRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC H.OR ENG. PERMIT VALIpATION
ADDRESS SPECIAL CIRCUIT 5.00 I
ZIP ITEMP.METER OR POLE INS. 15.00
Ars
ADDRESSDDRESSMOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
0¢ i
r
02 LICENSED CONTRACTORS DECLARATION
a 2w I hereby affirm that I am licensed under provisions of Chapter 9 IS LAN GATE
(contmenuing with Section 7000)of Division 3 of the Business and
G < N BLDG. ELECT PL❑G. C .
H 0 z Professions C and my li ase is in full for d
Licens CI s �' Lic.Nunthcr_(Qp_aly�
9 w H w Datc � CoNraclor4 LJ/ eM�
a BUILDING PERMIT
mon OWNER-BUILDER DECLARATION INFORMATION
X ; y I hereby affirm th al I am exempt from the Contractor's License MISC.- REFER TO ORD
H LL o v, Law for the following reason,(Sec.7031.5,Businessand Professions pERM1T ISSUANCE 6.00 VALUATION $/FT.
S w 0 Code:Any city or county which requiresa permit toconstrucl,alter,
a: ¢ < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i 0,
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9(consmencing with Section 7000)of Division 3 oflhe
14 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
H $ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(8500).):
❑ 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 Be 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 Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who docs Such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself ar through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement 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 im- RES IND CON PB Omar
.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors in construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:T'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractor(s)licensed pursunnl W
theCysstractor's License law.
f� SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
reo11 ame arta er Sec ,B.&P.C.for this WATER HEATER W/VENT 4.00
Date�ifH1 -Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKIi RS'COMPIiNSA'fION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-inone,X ZONING ENG.SITE N0.or a certificate of Workers'Compensation Insurance,or a cerlif ted
copy thereof(Sec.3800,Lab C.).
Policy No. Company
0 ❑ CerllHed copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z ,❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ Y ❑ N❑
~ rn PERMIT ISSUANCE' 6.00
LU RTIFICATE FROM WORK ISRS' FLOOD ZONE a.L.U.C.
W � COMPENSATION INSURANCE PLG.CONTR. LOC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [:] N❑
hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
ly H mil is issued,I shall not employ any person in any manner so as to
Q W become subject to the Worker''Compensation Laws of California.
Date A licam BUILDING
a pp ALTER OR ADD TO MECH. 4.00
} rn NOTICE TO APPLICANT: If,after making Nis Cenifeate of Ex-
Z emption,you should become subject to the Workers'Compensution APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I00001C.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(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and state Nauhemove. VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with:JI oily an I county PLUMBING
ordinances and state laws relating to building conslruclion, and BOILER•COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ahuve-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,j Idgnients, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
in any way accrue ax nst mid City in consequence of the
gran 'ng of thispermit. -• MECH.CONT. LIC.NO. MECH.
17 .3 TOTAL TOTAL
Srefute 'Applicant tractor [)AS
OFFICE COPY