5713 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION - PERMIT NUMBER
prUICmND APPLICATION & PERMIT
AORE55
p�f BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
5713
OWNER'S _ PLAN CHECK VALIDATION
NAMEI �/� OTY.
1 . ELECTRIC PERMIT FEE
NTRA PHONE�/ "
NAME"^cr Rs UTLETS-SWITCHES-RECEP 5.00/1.00
C �. L.C.NG. 2-.�lFl LIGHTING FIXTURES 5.00/1.00
corvr AOroR's
Ass PPLIANCES-RESIDENTIAL 4.00
ODR �/+
- PHONE )_rJ F'J1f PANELS 5.00 DATE OF APPLICATION
agcuOECrI
SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER - 4
LIc.rvO. SIGNS TRANS. 3.00
nooaEss ervG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 15.00
APPLICANTSDDRESS
A ' MOTORS SEE FEE SCH.
,
SERVICE CHANGE 10.00 •7/ /��
o¢ i
-02 LICENSED CON'TRACT'ORS DECLARATION
M U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(cummencin will,Section 7000)of Division 3 of the Business anA
¢ m g BLDG. ELECT. PLG. MECH.
0 w Z Professions Cod' nd my license is in full force unit elf•c ❑ ❑ ❑ ❑
0 O w- License Class -I Lic.Number___L�(_
wr DateS/l Contractor_
tete OWNER-BUILDER DECLARATION BUILDING PERMIT
a o d u INFORMATION
X 3 LL I- 1 hereby affirm Thal I am exempt from the Contractor's License MISC. REFER TO ORD-
u_o j law lin the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
H _ 'PERMIT ISSUANCE 6.00
w0 � Code:Any cityor countywhich requires a permit to construct,alter,
F ¢ improve,demolish,or repair aO Structure,prior 10 Its Issuance,also ELEC.CONTR. LIC.NO.
¢¢ D PY P ELEC.
, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractors License
H z<
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Oiic
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢h$ the basis for the alleged exemption.Any violation of Section 7031.5 , $ DRIES TY E CONSTR.
by any applicant fora permit subjects the Ga civil penalty ar^AI `F
of not more than five hundred dollars the ap).. ALTER-DRAIN&VENT-WATER (EA.) 4.00 l
l:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00
their ade compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON.. 4.00 opertinO
Qy
Code:The Contractor's License Law docs 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-
Imenls are not inlcnded'or offered for sale.IL however,the building GAS-EA.SVSTEM-11NC.40UTLET$ 4,00
otimprovement 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 did not build or im- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,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 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 projecis with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200it/8.00 TRACT NO. PARCEL NO.
re.❑ I am exempt under Sec..,RAP.C.for this WATER HEATER W/VENT 4.00
son
Owner Date WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy lhersol(Scc.3HOO lah-C)
Policy Company
O ❑ Ci rlifted copy is hereby funis call.
FIRE SPOINK ENERGYTP4
Z Z I Cest ifi' Coy s f wy'Js [be cilY inspection division.
O p t- 1.0i MISC.- REFER TO ORD. v❑ N❑ v ❑ N❑
� N CERTIFICA'IHOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE . 6.00 FLOOD ZONE A.LU.C.
LU > COMPENSATION INSURANCE PLG,CONTR. LIC.NO, PLG.
CIL Z (this section need not be completed if the permil Is for one TOTAL Y E] N❑ y[3N❑'
hundred doll..(S 100)or less) e
U O 1 Certify that in the performance of the work for which this Par QTY MECHANICAL PERMIT -'FEE FEE,SUMMAli1/ x
LL F ell is issued,1 shall not employ any person in any man cr sp as to
U become su cct ttpp the Worken'C pe v' n of lifomia. �[
Uu DatcY(6�Applicam ALTER OR ADD TO MECH. 4.00 BUILDING ' /,�.SU
} W NOTICE"'O APPP ICANI': If,alto making this Certificate of F:x- T
2 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(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op00CF.N1) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1Q0WQF.M.) 5.00 SEISMIC FEE s?J
I hereby offne, ][,at 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 HEATING UNIT(OVER 100,000 B.T17
Lender's Name .U. .50 ELECTRIC
I certify.that l have read this application and state that the abuse VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county - - PLUMBING
ordinances and state laws relating to building construction,and BOILER-COAT 13 H.P.or 100,000 B.T.U.) 4.00
s hereby authorize representatives of this city to enter upon the
above-mentioned property fur BOILER-COMP(Or 100,000 BTUI SEE FEE SCH: MECHANICAL'
(We) agree to save, indeminspection purposes.nify and keep harmless the CRY of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE' 3.00 CONST.TAX
may in any way scene against said City in consequence of the
gmntingofthis nit. MECH,CONT. LIC.NO. MECH. '
TOTAL TOTAL
Shmalure ol Applicanitcontractor Date
OFFICE COPY