1512 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMI UM
BUILDING APPLICATION III PERMIT 512
--f ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OW33-1
NER'S - I - � '-, - _---. —"'�"'� PLAN CHECK VALIDATION
"AME �` ELECTRICPERMIT�
PNONE ^ :-
ONTR CTORS
NAE 7 OUTLETS-SWITCHES-RECEP 5.00/1.00 S
�-
s Llc. yKfu LIGHTING FIXTURES 5.00I1.00
7 CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDA SEE
loo hk"er. $,,I, PHONE PANELS 5.00 DATE OF APPLICATION
..CH,TEcT SIGNS 8 PLAN CHECK FEEP.C.NO.
ENGINEER
LOC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zlv EMP.METER OR POLE INS. 15.00 40P aooAesa Ts MOTORS SEE FEE 0.00 s
SERVICE CHANGE 10.00
W o o LICENSED CONTRACTORS DECLARATION
<uup I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
u Q� (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D - Professions Cod a license is in full fo a an effect ❑ ❑ ❑
z D`� - License Class Lic.Number
0 N w Datc Contract.,AM
a >< BUILDING PERMIT-
¢ ¢ W u OWNER-BUILDER DECLARATION �_'- .' INFORMATION° -`
wILH 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
F u w 7 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE -600 VALUATION` SIFT.
my Code:Any city or county which requimsa permit to construct,alter, of -% V
Q UO a Improve,demolish,or repair any structure,prior to IIS Issuance,also ELEC.CONTR. LIC.NO. ELEC. / I
' wDLL requires the applicant for such permit to file a signed statement that TOTAL (/` PERMIT TO
u he is licensed pursuant to the provisions of the Contractor's License
ri> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and DTV, ++'C,"- .PLUMBINOIPERMIV g PE!a:
¢ r E the basis for the alleged exemption.Any violation of5edion]031.5 Y STORIES TYPE CONSTR.
n ; 9 by any applicant for a permit subjects the applicant toacivil Penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP 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,AREA,COND. 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 re through his own employees,provided that such improve- GAS-EA.SYSTE C 4 OUTLETS 4.00
menta are not intended or offered for tale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS•EA.SVSTE V 4 BUILDING USE
builder will have the burden of proving that he did not build or im- RES NB CON PB Otner
prove for purpose of sale.). IN DUSTRI AL WAS TER. 20.00 �❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLER 5 .00 ASSESSONS 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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-ST t/8.00 TRACT NO, PARCEL NO.
❑ 1 am exempt under Sec. .BdPC.for this WATER HEATER W/VENT 4.00
reason
Date Owner 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 NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(Sec.3800,Lab.C.))0
Policy e&
No. at)gsaMAPCQ_Company J e au
O q Certified copy ish reby furnished. �� FIRE SPRINK ENERGY T]a
Z Z ■ Certifiy �yy flied with y Inspection division.
0 Applicant (AJ�,C �Y -IV, k1 MISC.- REFER TO ORD. yNE] y [3 NQ
m PERMIT ISSUANCE 8.00 •� FLOOD ZONE A.L.u.C.
� CERTIFICATE OF E%EMPTION FROM WORKERS'
Lu COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. O 0� Y❑ N Y C] N❑
d D (This section need not be completed if the permit is for one TOTAL
Z h.ndreddollan(S100)O,less.)
U 0 1 certify that in the performance of the work for which this per C d - m- " ( S•,.?,FIR
6${IAIMARYi,.m.°'r
LL F- mit is issued,1 shall not employ'any person in any manners.as to P 7. . ,P --'MECHANICAIL PIRMIT - ti flEl- - iv
V become subject to the Workers'Compensation Iowa of California /�
0 y Date Applicant ALTER OR ADD TO MECH q 00 BUILDING (p a
} to NOTICE TO APPLICANT: If,after making this Cenificate of Ex
H Z emption,you should become subject to the Worken'Compensation APPLIANCE 4.00 PLAN CHECK
provisions .f the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO lOpODQF.ML) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10403C.F.M) 5.00 SEISMIC FEE s�p�
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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.1 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC 5-zi
1 certify that 1 have read this application and state that the above VENT'
LATION FAN (SINGLE) 3,00• n information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 4.00
.hereby authorize representatives of this city to enter upon the BOILER-COMP lover 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 and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue againal tai City in consequence of the
gnnti gof th it. MECH.CONT. LIC.NO. MECH. 3
TOTAL 90 p
1 TOTAL I" /
Si ature of Applican ontractor Det - •ti 2 ?^ .e`x"
OFFICE COPY