4272 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENTI FICAT ION PERMIT NUMBER
node ss APPLICATION & PERMIT 4272
0,51 /L GO L7/L / BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE /y
5,4/_ e-MG PHONE
CONTRACTOR'S
NAME 5 ' OUTLETS-SWITCHES-RECEP 5.00/1.00 3S� 9�J/P3
CdA--i LIC.NO. LIGHTING FIXTURES 5.00/1.00
cG TR.C& ^ PPLIANCES-RESIDENTIAL 4.00 .e--
�(, ADDRtEQSa E��1� �.X o
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5-DD PER ION
Z11 EMP.METER OR POLrIAWLJ 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHAN 10.00 I/�/�/�/p/gyp
W o o LICENSED CONTRACTORS DECLARATION City 4� / "�nE
a v v I hereby a(fnthat I am licensed under provisions of 9 I Y O upertino ISSUANCE DATE
m
m < w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H wz Professions Code, d my license is in full for and f cl ❑ ❑ ❑ ❑
z O u License Clasp J Lic.Num
g m H'a Dat 11,�b Contmcto
a s BUILDING PERMIT
w u OWNER-BUILDER DECLARATION INFORMATION
a o - MISC.- REFER TO ORD
X ; v y I hereby affirm that I am exempt from the Contractors License VALUATION
u,o a
m Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 CO-
'a
� (�Code:Any cityor county which requires a permit to construct,alter,
rt ¢ ¢ improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL �/ L-- PERMIT TO AjC7
E
$ he is licensed pursuant to the provisions of the Contractors License
z i
Law(Chapter 9(commencing with Section 7000)o(Divisian 3 of the /Ivit//Ti(J
a Business and Professions Corbel or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
siD
H $ the basis for the alleged exemption.Any violation oto acN it malty _ STORIES TYPE CONSTR.
i3 by any applicant fora permit subjects S500).licant toacivil penalty ALTER-DRAIN -WATER LEA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW 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,GOND. 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- GA$-EA.$VSTEM-11NC.40UTLETS 4.00
meats are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SV STEM-OVER 4 (EA) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Osner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ L as owner of the property,am exclusively contracting with ❑, ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade: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 con(ractodsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PAR LNo.
❑ I am exempt under Sec---B.&P.C.for[his WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of comm(to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thereoffSec.3800,Lab.
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ZO ❑ ant copy i� d wl C e city ins ctiapC n n;vs;o". MISC.• REFER TO ORD. ❑ ❑ ❑ ❑
Applicant , v N Y N
W CERTIFICATE OIr EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.0
L COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG, Y[:] N❑ v C] N❑
O. O (This section need not be completed if the permit is for one TOTAL
M Z hundred dollars I$100)or less.)
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
L I- mit is issued.I shall not employ any person in any manner so as to CITY. MECHANICAL PERMIT FEE'
U become subject to the Workers'Compensation Laws of California.
W
Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING CO
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F Z emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK / 7
,provisions of the Labor Code, you must forthwith comply with FEE e
U such provisions or this penni(shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE 4CRO
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.).
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COtftP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU1SEE FEESCH. 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 which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of (lies
grand of this per�}}t 'n MECH.CONT. LIC.NO. MECH. a
oma, //. (Y✓� 9'/ 3 -$3 OTA L TOTAL
Si cure of ApplicantlCnntrsvto, Date
OFFICE COPY