1545 APPLICANT TO FILL IN INFORMATIONWTHIN RED LINES - USE BALL POINT PEN ONLY
.
BUILDING PROJECT 1 DENTI FICATION PER T NUM
. :aDILDING APPLICATION & PERMIT- /�
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-_ � BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S
PLAN CHECK VALIDATION
[NAMED
. OTY. ELECTRIC PERMIT FEE
�PHON ^.
R'S
�/3--/4 UTLETS-SWITCHES-RECEP 5.00/1.00 -
� (,,/ //)w uc /z..Qj ILIGHTING"FIXTURES 5.00/1.00 -
ADDRESsroms - L+� APPLIANCES p RESIDENTIAL 4.00
�' 'j E �1 v PANELS 5.00 DATE OFAPPLICATION
ARRCHITECT SIGNS - ' - 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER,
LIc.No. SIGNS TRANS. 3.00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION '
ZIP TEMP.METER OR POLE INS. 15.00 n�
APPLICANTS - - MOTORS - SEE FEE SCH, o\//
ADDRESS ooREss
SERVICE CHANGE 10.00
'02 LICENSED CONTRACTORS DECLARATION
<Er u I hereby affirm that I am licensed under provisions of Chapter 9 CI ^^ ISSUANCE DATE
(commencing with Section 7000)of,Division 3 of the Business and
Gi ¢ y BLDG, ELECT. PLG. ],MECH.
F 7 z Professions Cod and y icense is in full fo '•nn f
O i= C License C a Lia NumbeAY-3 .
F u, F J Data Contractor. 19821
¢ x s OL BUILDING PERMIT
a z wsC
- OW ER-BUILDER DECLARATION INFORMATION
' ° - MISC. REFER TO ORD
>. 0 ' I hereby affirm that Dam exempt from the Contractor's License
o' 004 Law forthe following reason.(Sea 7031.5,Business and Professions PER T iDilNCE VALUATION 5/FT.
Code:Any city or county which requires a permit to construct,alter, 6.00
Or Q ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC
La X m, requires the applicant for such permit to file a signed statement that TOTA.LPERMIT TO
he is licensed pursuant to the provisions of the Contractor's License n�
zi Law(CImpter9(commencing with Section 7000)of Division3 ofthe r
f i o Business and Professions Cod,)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ar $ the basis for the alleged exemption.Any violation ofSection 7031.5 _ STORIES TYPE CONSTR.
a3 _ by any applicant for.permit subicostlm applicant loacivilpenalty gLTER-DRAIN -WATER (EA.) 4.00
GO not more than five hundred ):
dollars(5500).
❑ I,as owner of the properly,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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself Turns re through his own employees,Provided that such improve
or improvemenotnt intended or within on "atSale.G If, bebuildingowner' GAS-EA.SYSTEM•1 1NC.4 OUTLETS 4.00
or improvement is sold within one yew of lie didtinn,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that hC did not build or int- RES IND CON PB Orn.,
prove 1.as owner purpose of the
INDUSTRIAL WASTE INTER. 20,00 0 El � � ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business I 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 contructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,B.&P.C.lot this WATER HEATER W/VENT 4.00g �• -
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK 17RS'COMPI:NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sel&insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
21p�!,?
Lab.C.)pany -��O reby furoisheJ' FIRESPRINK ENERGY TY4
Z Zled with the city inspection division. ❑ ❑ ❑ ❑MISC.- REFER TO ORD.OtZv V N V N
= N CERTIFICATEOIc EXEMPTION b-ROM WORKERS' PERMIT ISSUANCE 6.00 '�� FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.CL
Z S( This section need not be completed if the permit is for one _ TOTALV❑ N� V N�
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LLH mit is issued,1 shall not employ any person in any numner so as to
O w become subject to the Workers'Compensation Laws of California.
Dale Applicant BUILDING
N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
Z emplion,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=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG U N IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3,00
information is correct. 1 Cto comply with all city and county PLUMBING
ordinances and state laws, rellating to building construction, and 130ILER-COMP(3 H.P,or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(BEE FEE SCH. MECHANICAL
above-mentioned properly 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
granting or this Penni MECH.CONT. LIC•NO. MECH.
TOTAL. TOTAL
n D Applicant/ConBactor Datc
OFFICE COPY