6737 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
y' aDILDING APPLICATION & PERMIT
nooRE}s
�(�^1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6737
OMsER'S //• - I PLAN CHECK VALIDATION
rvnmE QTY'. - ELECTRIC PERMIT - 'FEE
' H\ vnONE�53 -
CONTRACTOR'S OUTLETS-SWITCHES-RECEP 5.00/1.00
a C.No. " Q LIGHTING FIXTURES 5.00/1.00
ADDRESS APPLIANCES PPLIANCES-RESIDENTIAL 4.00
• ADOTRESS ['�
6'1 PRONC l'f PANELS 5.00 DATE OF APPLICATION
ARcwrecr SIGNS 6.00 PLAN CHECK FEE P.C.NO.
Do
ENGINEER
Ltc.NO, SIGNS TRANS. 3.00
ADDREOR SS ErvG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
AESrs
ADDDRDAESS MOTORS SEE FEE SCH.
S
SERVICE CHANGE 1OA0
0 LICENSED CONTRACTORS DECLARAT ION
a u s~a 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N "' (commencing with Section 7000)of Division 3 of the Business and
a a BLDG. ELECT. PLG. MECH.
o i I'rul'essio is Cud Ind my licca se-is in full forqq��an ff;¢Ij. ❑ ❑ ❑ ❑
zovwi- License•CI ss_ Con Numner-"l-D 1
o Z r D Dute J.Cl
�t _Contractor� n.,_
Y s �. BUILDINGcP.ERMIT
¢ a OWNER BUILDER DECLARATION sr+
a a w INFORMATIONa
oAD MISC.- REFER TO ORD
F
; N I hereby affrnn that 1 am exempt front the Contractor's License VALUATION $/FT.
F .. o a Law for the following reason.(Sec.7031.5,Businessund Professions PERMIT ISSUANCE 6.00
Code:Any city.,County which re4uirnsa permitMconstruct,ulleq 2 /a0
Qrt¢Q improve,demolish,or repair any structum,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
O C requires Ore applicant for such permit to file a signed stutemcN that TOTAL PERMIT TO
a w m tic is licensed pursuant lo the provisions or the Contractor's License
r z r
Law(Chapter 9(commencingwith Secrion7000)ofl)ivision 3 oflhe G�Q
- a
business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ae= $ the basis for the alleged exemption.Any violation of Section 7031.5 1xiJ JZTORIES TYPE CONSTR.
a � by any applicant lin a permit subjects the applicant too civil penalty ALTER-DRAIN (EA.)
o1'not more than live hundred dollars f 5500).): -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 C.! OU 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,AR EA,COND. 4.00
nt
Code:'Che Coractor's License Law docs not apply to an owner of
Y
himself
who builds or sen m ploy ereom and whoadoes t such improve work FIXTURES-PER TRAP 4.00 so.Fr.FLooR AREA TOTAL ACREAGE
..Cut or through his Own employees,provided that such implove-
mcnssarenmintcndedorolfcredlisrsalelfhowever,the building GAS-EA.SYSTEM-11NC.4OUTLETS 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-
provel'orpurposeofsalcJ. INDUSTRIAL WASTE INTER. 20.00 RES IND CON PR Cure,
❑ I,as owner of tire property,am exclusively Contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 5.00 ASSESSORS PARCEL NO.
and Professions Code:I'he Contractor's License Law does not apply
to in owner of property who builds or improves thereon-and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a mmrucl.R0 licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam ccentpt under Scc. .B.&P.C.for Otis WATER HEATER W/VENT 4.00
Ivioun
Owner Date WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORK 17RS'COMPI;NSA I ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate cfeemsent to self-insure.
or it c"Of¢Wee of Workers'Compensat ion`n Insurance srosr`Ja�certified ZONING ENG.SITE NO.
I'oIICthe,Y No�'ll.•1-11;L-omponY� AI� =
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z , �Certili'it cu s fit` with the city inspection division.
M, la r `I p MISC.- REFER TO ORD. y N y N
FOU pian -" ❑ ❑ ❑ ❑
IM CERTIFICATE CERTIFICATE OF L'XI';MPIION 17ROM WORK ERS' PERMIT ISSUANCE 6.00 PL000 ZONE A.LU c.
LU >_ COMPENSATION INS FRANCE PLG.CONTR. LIC.NO. PLG.
C 0 (P
his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
=) Z hundred dollars($100)or lines.)
L) O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY;
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Ed Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} 0 NO'1'ICE�TO APPLICANT: 11',al'te,nmking this Certificate of Ex -
? cntptim,you should become subject to the Workcri Campensatim, APPLIANCE q.00 PLAN CHECK
provisions of the Labor Code, you nwst Ii..thwith con ply with FEE
U such provisions or this Permit shall be deemed revoked AIR HANDLING UNIT(TO 1O=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the 3097 Civ.c)�Icc °f she work for which this permit is issued(See MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lander',Name HEATI NG UN IT(OV 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
ordinances is state. I agree to comply with all my and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.1A) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to cove, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertinoagainst liabilities,judgments, costs and expenses which CONST.TAX
Ola in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gra og of this pe MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signamr I'Applicant/Contria,or Da
/ ` OFFICECOPY