4355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING I APPLICATION & PERMIT
,
°y12J5_&0 poppy tq� . 4355
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
^, OWry ER's PLAN CHECK VALIDATION
A NAME
&P-EGoey re GIBE TV. ELECTRIC PERMIT FEE
`f �adNE
CCONT ACTORS UTLETS-SWITCHES-RECEP 5.0011.00
uC.NC. LIGHTING FIXTURES 5.0011.00
DNTRA DRs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 - DATE OF APPLICATION
ARCHITECT .S•IGN.S• 6•.DD PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG. - SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
ARMOTORS SEE FEE SCH.
E55
AOGRESS
SERVICE CHANGE 10.00 �� 3
o O LICENSED CONTRACTORS DECLARATION
awr
Quo I hereby uffinn licensed 1 oat IieenA under pnwisions of Ghupler P ISSUANCE DATE
w z w (commencing with Section 7000)of Division 3 of the Business and
Q N
F H i Professions Code,and my license is in full force and effect Q QpBLDG.(commencing I PLG. MECH.
❑ ❑ ❑
o z w W License Class Lic.Number
Date Contractor
a y e I gLg]41 O PERMIT
2 w OWNER-BUILDER DECLARATION P 2, tl INRQ/�MATION
A.
;u I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD 1.
H a. OJ Law for the following reason, 7031.5,Businessand Professions pERM1T ISSUANCE 6.00 VALUATION S/FT.
Code:Any city or county which requires a permit to construct,aheq ��d.-ta�no
Saa < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. PGn
u wDLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
w F
rz • Law(Chapter 9(commencing with Section 7000)ofluvislon3ofthe 6Q0oRif
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r$ the basis for the alleged exemption.Any violation of Svetion 7031.5 1l,STORIES TYPE CONSTR.
a by any applicantfor a permit subjects the applicant to v civil penalty gLTER-DRAIN -W VENT-WATER (EA.) ry00� S N��I
of not more than five hundred dollars(5500).): Y
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 uv 5. TS
their sole compensation,will do lite work,and the structure is not
intended or offered for sale (Sec. 7044, Business end Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner ml'
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 Sa.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve, -
mentsarenot intended or offered for sale If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4,00
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 slid not build or im- RES IND CON PB Other
th
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ 0 ❑
❑ 1,as owner of the property,ton 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 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 u contramoos)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.Ga it WATER HEATER W/VENT 4.00
reason
')ate Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK IiRS'CONIPIiNSAT'ION DIiCLA RATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to sell'-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a cerified
copy t hereof(See.3800,Lab.C.).
Policy No.-Company-
0
o. CompanyO ❑ Certified copy islhereby furnished. FIRESPRINK ENERGYT24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
p Applicant Y ❑ N❑ Y ❑ N[:]
CC rn PERMIT ISSUANCE 6.00
LU - Cf!RTIFICCOMPH EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.C.
- W � COMPIiNSATION INSURANCE PLG.CONTR. LIC.No. PLO.
CL 0 (This section need not be completed if the pernin is for one TOTAL Y E] N Y 11 N 1:1
hundred dollars IS 100)or less.)
L) O 1 certify-that m lite performance nl the..,it fnr which His per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner so us In yqG/
O W became subject to the Workers Compensation Laws of Caliti rnia. BUILDING PC
Do [)ate Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H ? emplion,you should become subject to the Workers;Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code, you must lorhwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUC'r1ON LENDING AGENCY AIR HANDLING UNIT(OVER IO,ODOQF.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency fnr 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(OV ER 100,000 B.T.U.17.50
Lender's Address- ELECTRIC
I certify that I Have read this application and$tate that the above VENTILATION FAN (SINGLE) 3.00
• information is correct.I agree to comply with all city and county PLUMBING
ordinaneesand %tote laws relating to building coostruction, unll BOILER-COMPI3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to eater upon the BOILER-COMP (Over 100,000 B7U1 SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
ton In any way untrue against Said City in consequence of fire
6r ingofthis per it s MECH.CONT. LIC,NO. MECH.
Z TOTAL TOTAL C,2? 0
nate
g p ant/Contractor int for Uate
OFFICE COPY