3400 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING CT I DENTI FICATION PER ER
1) BUILDING APPLICATION & PERMIT 3400
Y AD Es e�
S BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
O NER'a v _rI�'{� - PLAN CHECK VALIDATION
" E CITY. ELECTRIC PERMIT ` FEE
ONE
CONTRACTION
N ME OUTLETS-SWITCHES-RECEP 5.00/1.00
I LVIli LIC.NO, 9/ NLIGHTING FIXTURES 5.00/1.00 -
CONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
N12
2
AD Rf5 L
/ J PHON _3 Jd PANELS .5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR - SIGNS 6.00
ENGINEER
' < uc.NO SIGNS TRANS. . 3.00 -
ARC H.HE R ENO. SPECIAL CIRCUIT 5.00 .• - PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00
APPLICANT
ADDRESS
MOTORS SEE FEE SCH. `
SERVICE CHANGE 10.00 . • �/ �3
Doo LICENSED CONTRACTORS DECLARATION /
< u u 1 hereby affnn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
2w (commencing with,Section 7000)of Division 3'of the Business and
BLDG. ELECT. PLG. MECH.
F D i Professions Code,and my license is in fallmb force and effect ❑ ❑ ❑
Z o= License Class Lic,Number.
4 F Date _ CONNICtmr
a m E V - BUILDING PERMIT
Ie ¢ 'OWNER-BUILDER DECLARATION
F o a D MISC.— REFER TO ORD INFORMATION
{`u'x ; s- 1 hereby affirm that I am exempt from the Contractors License
yyJ Law forthe following reason. 7031.5,Businessami fissions pERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Anycity orcounty which requires a permit to construct,aIter,
2 2 Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO, ELEC.
e-wo u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencingwithSection 7000)ofDivision3ofthe Ld(r ONL
f 4 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES. TYPE CbNSTR.
a ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.)of not more than five hundred dollars($500)): r
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE - 200
their sole compensation,will do the work,and the structure is not , OCL.GROUPRES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,EA,CON D. 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-
mentsarenotintendedorofferedforsale.l E however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
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 CON PB -0mer
prove for purpose of sale). I NOUSTRIAL WASTE INTER. 20.00 � O
O f us owner of the property,nm exclusively contracting with
licensed contractors to IODIIIUct 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 forsuch projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/5.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—,WaP.C.for this
reason WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have u certificate ofconsenl to self-Insure,
or a certificate of Workers'Compensation Insurance,ora certified ZONING ENG,SITE NO. _
copy thereof(Sac.3800,Lub.C.).
Policy No.—Company Company
Q ❑ Certified copy is,hereby furnished. FIRE SPRINK ENERGYT-24
Z2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Applicant V N V N
CC O PERMIT ISSUANCE 6.00
CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.c.
LU — COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 G (This section need not be completed if the permit is for one TOTAL Q V❑ N� V rv�
:DZ hundred dollars(S100)or .S.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1— mit is issued,1 shall out employ any •rso in any n nnar so us to
U hccopc s he Workcrs' in sat' Laws
U i� Datft_r�Apph°ant ` ALTER OR ADD TO MECH. 4.00 BUILDING
_ m NO CE TOA WN"' IL Lifter making this C I icate of Ex-
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 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby„affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the ped'ormance of the work for which this permit is issued(Sec. MICROFILM
.1097,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 ubove VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city and county PLUMBING Q d0
ordinances and state laws relating to building constnstinn, and BOILER-COMP(3 H.P.Or 100,0008.T.U.) 4.00
hereby authorize representatives of this city lO enter upon the BOILER-COMP(Over 100,000 BTU(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 end expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any ay accrue again t said City in consequence of the
grant oft „pert it MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign are of Appf ant Contr or Date
OFFICE COPY -