14056 (3) 1 M APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDIN�i APPLICATION & PERMIT
ADDRE9'J f .N5S 14056
/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
BWrvee' �,.L L - PLAN CHECK VALIDATION
-� """" DTV. ELECTRIC PERMIT FEE;3,74,040e 1X5`7
PHONE
Co.TR�T Rs � �/ OUTLETS-SWITCHES-RECEP 10.00I1.00
NAME
sac.NO,-J LIGHTING FIXTURES 10.00/1.00
CONTRACTORSAPPLIANCES-RESIDENTIAL 4.00
AD '
DRESS 7
// ✓' ('� PHONE / '� PANELS' 10.00 DATE OF APPLICATION
ARCHITECT .//_- PLANCHECKFEE P.C,NO.
on
GAG PANELS (OVER 200 AMP) 20.00
ENGINEER
L'- sac.No. :U71570 SIGNS TRANS. 3.00
ARCH.ssrvc. � SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
� l
Aca l�VL~,J- zI EMP.METER OR POLE INS. 20,00
APPLICANTS MOTORS SEE FEE C
ADORES Illii(l/,y0��- c' SERVICE CHANGE 200,.0000
F o LICENSED CONTRACTORS DECLARATION 7- -0 /
Q 2 w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
m a u (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
�-�F o i Professions Code, license is in full for' a e 4% ❑ ❑ ❑ ❑
Z o,� - License lass Lic.Number JJ
9 f2 H t Date Contractor e• -
a m s /K! BUILDING PERMIT-
ID ¢ OWNER-BUILDER DECLARATION
a u INFORMATION
a'xr ;n m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o ¢ Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
m ..1 Code:Any city or county which requiresa permit to construct,alter,
Q Q¢ p Improve,demolish,or repair any structUTC,prior to Its IsSUJncr,SISO ELEC.CONTR. LIC.N0. - ELEG '
C a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w S he is licensed pursuant to the provisions of the Contractor's License - ^
rii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe IJ/Eyffi7-1_GIZe
x o Business and Professions Code)or that he is exempt therefrom and OTY- PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant to civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,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 does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorOffered for sale.If,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 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
'roveforpurposeofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB GO.,
❑ L 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. 6.00 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 a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lamexemptunder Sec. ',B.&P.C.for this WATER HEATER'W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
/ or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
T copy thereof(Sce.3800,Lab.0 J.
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
z
Certif co i de with m i jt eetion division. MISC.- REFER TO ORD.
O plicanl V ❑ N❑ Y ❑ N❑
cc T CERT114CATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.GONTH. LIC.NO. PLG.
CL Z ITHS scctidn need not be completed if the permit is for one TOTAL Y I-] N❑ Y❑ N❑
hundred dollars 1$100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- Init is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensalion Laws of California. -_A
i Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING IAJUVD(J
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,CN.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
1 certify thal I have neud this application and scute that the above VENTILATION FAN (SINGLEI 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.).6.00
hereby authorize representatives of this city to enter upon lire BOILER-COMP (Over 100,000BTU)SEE FEESCH, 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 10.00 CONST.TAX
m ny wa accrue against said City in consequence of the
ming th pe MECH.CONT. LIC.NO. MECH44 Zo .
pi TOTAL TOTAL- /�
are of Ap n Contractor �/✓(_ ate
OFFICE COPY