2447 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DEEFICATIO:N PERMIT NUMBER
BUILDING APPLICATION & PERMIT 2447
aoDREss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S "- "' '�>..r'• PLAN CHECK VALIDATION
AME OTY. ,ELECTRIC PERMIT.',` "X•,y''„ `F lli* ;
PRONE
• conrRAcroRs UTLETS•SWITCHES-RECEP 5.00/7.00
Na
1 LIGHTIN
LIC.N0.
G FIXTURES 5.0011.00
I
CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
ADDRESS
dho ' lvnon PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B.QQ PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS., 3.00
ARCH.OR END. SPECIAL CIRCUIT S,QO PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
w
02 LICENSED CONTRACTORS DECLARATION
< u u I hereby affirm that I am licensed under provisions of Chapter 9 A?,%tISSUANCE DATE
Naw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o = License Class Lie.Number p q
Q h H w Date Contractor
¢ ¢ W¢ OWNER-BUILDER DECLARATION 03PIZ�BUILDING;PEIIMIT�{e�ay)
o A " MISC.- REFER TO ORD +'' e�'INEORMATION,ss;•!ws.F.
K
3 w I- I hereby affirm that I am exempt from the Contractor's License
w0� Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISBUAN VALUATION •.g/FT.
! ;;0 Code:Any city or county which requiresa permit to construct,alter. 6.00
So
w Q 2O improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. IC.NO. ELEC.to
rs u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO F-
w$y he is licensed pursuant to the provisions of the Contractor's License p
r
Law(Chapter 9(commencing with Section 7000)ofDivision 3ofthe of y'a^ r - d' - ' - /N(=P9./�I (ej W-1_Jgy
f Business and Professions Code)or that he isexempt therefrom and OTY. ¢+; x PLUMBING.PERMITym_ ,r ? FEE
i o s
STORIES TYPE CONSTR.
¢ I- the basis for the alleged exemption.Any violation of Section 7031 5 a' ` '!
a. by any applicant for a permit subjects the applicant boa civil penalty ALTER-DRAIN (EA.) 4.00
of not marc than five hundred dollars(S500).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 is not
in[ nded or offered far 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
properly 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 INCA OUTLETS 4.00
ments are not intended or offered for ale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CONPB Osnar
prove for purpose of ale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with - 1:10 El . El ❑
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.) toocontra
the Conte ctor'sor hcenecLwilha contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. . PARCEL NO.
the Contractor's h projects
Law.
❑ lam exempt under Sec..,B.&P.C.for this WATER HEATER WIVENT 4.00
reason
Data Owner WATER SYSTEM 4.00 ACC.DATE .ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a"rtificate of consent Io selhinsure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T•24
❑ Certified copy is filed with the city inspection division. MISC.• REFER TO ORD.
Z p Applicant Y❑ N❑ Y ❑ ,N❑
~ va PERMIT ISSUANCE 8,00 FLOOD ZONE A.L.U.C.
LuCERTIFICATE E EXEMPTION FROM WORKERS'
UJ > COMPENSATION INSURANCE PLG,CONTR. LID.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars(I 100)or less.) y - N' u - -' a a- 1.- v. T..�-.
U O I certify that in the performance of the work for which this per- Oar • - NIECHANICALPERMIT .r FEE x;,y„', ,ih FEE SUMMARVy�'ti'
LL F mit is issued.I shall no employ any person r moaner so as to P v".
_t ,t;l
C) W hecompgubjEcy{Whe Wporken'Cptnpepsatio I'Cal'
y D@`mm _gGGl��,,P[A licant_slii''ff���a2�-]1 ALTER OR ADD TO MECH. 4.00 BUILDING /
} w NOTICE O A LICANT: If,a r ma nng,firs Certificate of Ex-
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 10,00DC.F.M.) 3.00
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
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097.Civ.C.).
Lenders Name H EATI N G UN IT IOV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have road this application and state that the above VENTILATION FAN (SINGLE) 3.00
coloration is correct. 1 agree to comply with all city and county PLUMBING
ordinances Rad slate 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 en1Cr upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. -MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to ave, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against aid City in consequence of the PERMIT ISSUANCE 3.00
graMf t1'is perms. MECH.CONT. UC.NO. MECH. ' ' ^. "^
TOTAL ,'_TOTAL�7'.' q
Slgn>�tre of Applicant Contractor DAC
OFFICE COPY