11194 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING - APPLICATION & PERMIT �I ��
r'• P O ESS `#
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
D1
OWNER S PLAN CHECK VALIDATION
42FffWrQ
I ( OTY. ELECTRIC PERMIT FEE 1
1 PHONE I
CONTRACTOR UTLETS-SWITCHES-.RECEP 10.00/1.00
Q ua rv04 23 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S �K PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE 297-�/��2 PANELS 10,00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMPI 20.00 - PLAN CHECK FEE P,0.NO.
O
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
noC".08 ENG. SPECIAL CIRCUIT 5,08 PERMIT VALIDATION
DRESSZlv TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS [v
SERVICE CHANGE 20.00
X o LICENSED CONTRACTORS DCC LARATION f/9
< v T 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w z i commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT, PLG. MECH.
F w i rofessions Code,and r fbf license is in full for 1 fje t ❑ ❑ ❑
z o y Licenso Cla L Lic.Number
m r Date Conlraclor� MItG
BUILDING PERMIT
a ¢ OWNER-BUILDER DECLARATION
iL o a U _ INFORMATION
w3 LL 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
H .. o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
ac o,Q Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CORNER. LIC.NO. ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL ' PERMIT TO
A w m a he is licensed pursuant to the provisions of the Contractor's License M
Fz>
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe [:
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
EE = tiro basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.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. 5.00
Code:The Contractor's License Law does not apply to an owner of
. property who builds or improves thereon,and who docs such wok FIXTURES-PER TRAP 5.00 SQ IT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
mems are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-i INC.4 OUTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
RES IND CON '- PO Olher
prove for purpose of the J. INDUSTRIAL WASTE INTER. 30.00
❑ L as owner of the properly,he project
(Se contracting with
licensed contrsclod to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
El El El 1:1 ED
and Professions Code:The Contractors License Law does not apply
to tr owner of property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contracmr(s)licensed pursuant In SEWER-SANITARY-STORM EA.200ft 10.00
the Contractor's License Law. / TRACT N0. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reusnn
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to sel Ginsure,
or a certificate of Workers'Compensation Insurance,or a cyrliIad ZONING ENG.SITE NO.
opy EC.f(Sec.3800,Lab,CJ.
P y No. Company
tERTIFICATF
rtif•J copy is hereby tarnished.
Z Z rl if•d Copy is fi with the city inspection. FIRE SPRINK ENERGY T24
Ot .7"'n"( MISC.- REFER TO ORD. v NO Y ND
C' N PERMIT ISSUANCE. 10.00
CC - OF SAEXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.N0, PLG. Y N Y
CL 0 ('Phis section need out be completed if the permit is for one TOTAL N
hundred dollars IS 100)ur less)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE ` FEE SUMMARY
IJ_ I. mit,is issued,I shall not employ any person in any purer so as to
U
O become subject to the Workers Compensation Laws of California. BUILDING
Ed Date Applicant ALTER 08 ADD TO 5.00 Q
} to NOTICE TO APPLICANT: If,after makillg this Certificate of Ex- -
h Z emption,you should become subject to the Workers'Compensation APPLIANCE5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING U ti pWF.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER .) 6.0SEISMIC FEE -
I hereby affirm that there is a construction holding agency for EXHAUST HOOD IO 10,000) 5.000
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Address H EATI N G U N IT(OV ER 100,000 B.T.U.)9.50
ou
Lender's AAddress E LECTR I C
• I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 7
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL J Q
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 w PERMIT ISSUANCE 10.00 Q7`7 CONST.TAX
may in any way accrue against said City in conseque the
granting Of this permi. MECH.CONT. LIQ NO. MECH.
TOTAL L d.- TOTAL
a ore of A plicant/Co motor Data
OFFICE COPY