7155 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - US LL POINT PEN ONLY
i''•
BUILDING PROJECT IDENTI PERMIT NUMBER
ION APPLICATION & PERMIT ' -
aOlas 715 5.
n&REs
3 O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
PHONE
4CTOR5
rvnmE UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00 IC.N0.
kCONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
IPHONE b PANELS S.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.Na. SIGNS TRANS. 3.00
ADDRRiOR SS era - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS - SEE FEE SCH.
AODR ESs
SERVICE CHANGE 10.00j�q�.
woo LICENSED CONTRACTORS UECLARATION
a U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ve<w (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m Professions Cod an license is in full forl',g�y9y4c f �r ❑ ❑ ❑
a O m License Class_ Lic.Number l�lJ
9 z r w )ate...�_.,Z_ $� Contractor 11 rJ
r s /0 fi BUILDING PERMIT
tc w OWNER-BUILDER DECLARATION
o A MISC.- REFER TO ORD INFORMATION.
F.
3 u I hereby affirm that 1 am exempt from the Contractor's License
U.
Law forlhe following mason. 7031.5,Business and Professions PERMIT ISSUANCE VALUATION S/FT.
H _ 6.00
Code:Any city or county which requirese permit tocmrsua c ,else
K< 0 improve,demolish,Or repair any rami to
prior to its issuance,also ELEC.CONTE. LIC.NO. - ELEC.
O LL requires the applicant fur such permit[o file a signed statement that TOTAL PERMIT TO
K m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commenciagwith Section 7000)ofDivision 3 ofthe /- O
4 Business unit Professions Code)or that he is exempt therefrom and 0TJY. PLUMBING PERMIT FEE
r es the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i;m by any applicant for a permit subjects the app toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE _2.00 OCC.GROUP RES.UNITS
their sole Compensation,will du the work.and the structure is not
intended or offered for sale(Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properlywho builds or improves thre
eon,and who doessuch work FIXTURES-PER TRAP 4.00 sO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve-
mentsamno(intended or offered for sale:If,however,the building GAS-EA.SYSTEM-I INC
.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,did not build or im- RES IND CON Pe Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El El
❑ I,as owner of the property,am exclusively contracting with '
licenv.t Contractors to construct the project(See.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 build's or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrxclods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.20014/8.00 TRACT NO. PARCEL NO.
❑,Icon exempt under Sec. - ,B.&P.C.fm this WATER HEATER W/VENT 4.00
rcasvn
Owner. Dale WATER SYSTEM 4.00 ACC-DATE ACC.FILE NO.
'WORK FRS'COMPENSATION DECLARATION WATER TREATINdMAJ 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,ora Certified
copy thereof(Sec.3800,Lab CA U
Policy No.-_ Company
O ❑ Certified copy is hereby furnished. 11ro� FIRE SPRINK ENERGY T-24
Z Z O'Cchified copy is filed with the city, inspection division. MISC- 1 "9'fl f�111T0 OR D.
FO phllcaol - Y❑ N❑ Y,❑ N❑
CC CERTIFICATE OF EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 6.00 ._
FLOOD ZONE A.L.U.C.
UJ COMPENSATION INSURANCE P .CONTE. ❑C.No. PLG. pp
d O (This section need nut be completed if the permit is for,orm /tf� K TOTAL J 0 '� Y❑ NY O N❑
0 Z hundred dollers(SI00)or less.)
U O_ 1 certify that in The performance of me work for which this perry QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become sub' it th�yorkers'C6. nsi i n w.s of�alifo
Ow ltate_/L A licant_�:t�0 0M.l ��a BUILDING
C � Pp ALTER OR ADD TO MECH. 4.00
} N NO'I'I P T APPLICANT: If,after making this Certificate of(ix- _
H Z 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 this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10p000.F.M.) 5.00 SEISMIC FEE
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,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address - -
I certify dhal l have mad this application and stale that the above VENTILATION PAN (SINGLE) 3.00 p.�
1 3 information is correct. I agree to comply with all city and county PLUMBING
'ordinances and state laws relating to building construction, and BOILER-CONP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. CHANICAL
above-mentioned properly 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit MECH.CONT. LIC.NO. MECH.
ip TOTAL TOTAL
StgnaFilra of App IcanllCon[rac�h Uale
OFFICECOPY