2634 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BUI LDI NG PROJECT IDENTIFICATION PERMIT N MBE �3
\ ' BDILDING APPLICATION & PERMIT
I
X AD REfia BUILDING -ELECTRICAL-PLUMBING-MECHANICAL -
L pJ , . . I PLAN CHECK VALIDATION
NANER'S /TDI/vL _. .
DTV. . ELECTRIC PERMIT 'FEE
PHONE
CONTRACTORUTLETS•SWITCHES-RECEP 5.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5,00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHICK FEE P.C.NO.
OR
ENGINEER LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 6.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 l� j 116
R
Woo LICENSED CONTRACTORS DECLARATION V
a L,L,I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Naw (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m i Professions Code,and my license is in full force and effect. ® ❑ ❑
i O B - License Class Lic.Number
2 Z O Date Contractor
a x s .p : ;BUICDING'PERMIlr,-._„nji'?
¢ ¢ w sai OWNER-BUILDER DECLARATION -, :x�,"?-INFORMATION,}j;^�,.,y'2;
W3 LL N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
F w o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 �.p VALUATION E/FT.
Code:Any city or county which requires a permit to construct,alter. PAM
¢ ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
0,
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
2 w he is licensed pursuant to the provisions of the Contractor's License
w > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and DTV. rt. �:PLUMBINOP.ERMIT.' +-d ,.r.FEE
the basis for the alleged exemption.Any violation of Section 7031.5 « -'r I +::;(,', a i1 !M.:",-. .« ,,.,"y,y y";,,._ STORIES ON51R.
by any applicantfor apermit subjects the applicanItoacivil Penalty ALTER-DRAIN8'V
VENT-WATER (EA.) 4.00 Ify of Cupertin
of not more 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 sale 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 don not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himse-, trupts are notthrugh intends Ownemployees.for Sale.
II,ed that however,
the
improve-
GAS•EA.SYSTEM-1 INC.4 OUTLETS 4,00
meets are not intended or offered for sale.IL 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- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. ' 20.00 ❑ ❑ ❑ ❑ ❑
❑ h as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 6 V.B. 5.00 ASSE55OH5 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason [M P
Date weer WATER SYSTEM 4.00 ACC.DATE ALC.FILE NO.
WORKERS'COMPENSp WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
-copy(hcmof(See.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy isherebyfumished. FIRE SPRINK ENERGYTZ4
Z Z ❑ Certified copy is file4.with the city inspection division. MISC.- REFER TO ORD, y❑ N❑ y ❑ N❑
O Applicant
~ vi PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU CERTIFICATE PE EXEMPTION FROM WORKERS'
W > COMPENSATION INSURANCE PLG.CONTR. LIC.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(S 100)ar less.) rt.. Y vv. - ';{,� r Y +'+L `y4'TL'^'0' 1- s st +e i;w+)S'yA _u "
UO mil1 certify iissuedh llin shallhnot employ any Pe the
nranYrmanlncrtsosas to OTY% 'k1 A4f fy MECHANICALS PERMIT4�cl;:ai 7FEEiff .. FEE BUMMARYyy° p,
LL. U become subject to the Workers'Compensation Laws of California. w ^-• '.Ii xxA imnd�.n'.e'i''�',4�''y jrt 'v'S'' t't""'"-" 'z °"
W Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /d Cr0
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
? emption,you should became 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 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMICFEE J�
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(Sec. 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.17.50 ELECTRIC
Lender's Address
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.TU.) 4.00
hereby authorim representatives of this city to enter upon the BOILER-COMP (0.,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, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grantingut this permits / y�,/ MECH.CONT. LIC.NO. MECH.
rC'h_0IA"Ut:4 4�CCPt� Z. . TOTAL M$ /6 -fillSignature of Applicant/Contrac(or Date
OFFICE COPY