2428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
. BUILDING PROJECT I DENTI FICATION CT
U SER
BUILDING APPLICATION & PERMIT n Q
ADDRESS T v
•s
y BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S )y. .3':""� f,i }j !"-� 1",- PLAN CHECK VALIDATION
r NAME OTy; . ' ELECTRIC PERMIT" -, FEE,
PHONE ..
coNTRAaons OUTLETS-SWITCHES-RECEP 5.00/1.00
NAM
- LIGHTING FIXTURES 5.00/1.00
LIC.No.
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
T ADORE95
PHory PANELS 5.00 PATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN LHECK FEE C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT $-QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT s MOTORS SEE FEE SCH.
ADORE SS y
SERVICE CHANGE 10.00 0 '�4%
woo LICENSED CONTRACTORS DECLARATION
¢ v I hereby affirm that I am licensed under provisions of Chapter 9 Q ISSUANCE DATE
Nan (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
Professions C a pnd m license is in full force and gcct.
z o m — License Class Lic.Number A�n1:1
e o Date Q d- CKl Contractor H ❑Y 'E J ��
¢ ¢ w e OWNER-BUILDER DECLARATION ns8U1LO RMT RMITfAYf.$'gj:
a- 0 A U MISC.— ER TO ORD -'.INFORMATION_
X ; w r I hereby affirm that 1 am exempt from the Contractor*s License
w0 Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION SIFT. .
ryM � Code:Anycity orcounty which requires a permit to construct,alter. 6.00
c aa 4.0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
is ¢ 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 i i
Law(Chapter 9lcommencing with Section 70001 ofDivision3of the s + - _I s}r V`ysl. NP
i Qo Business and Professions Code)or that he is exempt therefrom and QTY. iJ',.,PLUMBING.PERMIT s y A, 4+(IFEE;�t � TC%L'
the basis for the alleged exemption.Any violation of Sect ion 7031.5 .'_ > . ` v_ .."=. .,.s Sr/ 'o,.. «'.nP 9,!:?v:: STORIES �Y➢g RC�DyS[B.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 '7 fs't.
of not more than five hundred dollars(S500).):
❑ 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
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
marts 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
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB GO.,EI1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractorl s)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Dale Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that 1 have a Certificate of con at to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-I4
Z O 0 Certified copy is filed with the city inspection division. MISC- REFER TO ORD. ❑ ❑ ❑ ❑
A bean) Y N Y N
= to CERTIFICATE PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU
1 G COMPENSATION
EXEMPTION FROM WORKERS'INSURANCE PLG.CONTR. LIC.NO. TLOO.AL Y❑ N❑ Y❑ -N❑
(This sectidn need not be completed if the permit is for one _,{��
U 0 hundreddollarsthat in the
or
Of the work far which this per. dos 'y n .'+jI,S . 7e i � a 1`' it �.A M `"s,�;`'lt!;"FEE SUMM RYvx Y
certify p QTY '+ f MECHANICAL PERMli t,yvl r�„ FE�e" /$�, 1,.�[� M/j�a
YY
LI. l— mil is issued,I shall not employ any person in any manner so as to ,. 1t 1 `P p ;h A x k+,AfFpk 4 r.Sc
U become subject to the Workers' a soli s o(Califo a
O w Date Applicant qq ��� BUILDING 9 �O
a �"��— ALTER OR ADD TO MECH. 4.00 01 c7
} to NOTICE TO APPLICANT: If,after making this Certificate of EF
f" Z 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 TO 70,000 CF.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ADCEM) 5.00 SEISMIC FEE a
1 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 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 is correct. 1 agree to comply with all city and county PLUMBING
• ordinances and state laws relating to building construction, 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 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.
Cupertino against liabilities,judgments, casts and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way acen ' st said City in consequence of he V
gr o [Isis per I T
MECH.CONT. LIC.NO. TOTAL
P ! z+
II
Sipsalure a Applicant/Contractor Uatc ti,
OFFICE;COPY