4872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.BUILDING PROJECT I DENTI FICATION - OT
8BER
BUILDINGE5 - APPLICATION & PERMIT
ADDR5 v
b p� S`-nIr^-•� r BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
72
OWNER'S QG1 (� .T PLAN CHECK VALIDATION
NAM • �S1 �i OTY. ELECTRIC PERMIT FEE
S �6/fDNE
CORI5 OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
9_0r,51 uC.ND ILIGHTING FIXTURES 5.00/1.00
ro rRAC ' /� APPLIANCES-RESIDENTIAL 4.00
A3Y,[TO_RiSj.f/��]I/�(D10 r PHONF.�(�[�J 0 PANELS S.0B DATE OF APPLICATION
ARCHITECT SIGNS 6.OD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO.' SIGNSTRANS. 3.00
ZRICH0.END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 \
APPLICANTS MOTORS - SEE FEE SCH.
ADDRE55
SERVICE CHANGE 10.00
woo LI 'D CYNTRACTORS DECLARATION
-Q v� I hereby YI'i t that 1 nm licensed under provisions of Chapter 9 IV11
z i (commencing with Section 7000)of Division 3 of the Ilusi ness and
¢ C. ELECT. PLG. MECH.
F m z Professions CDB n my license iz in full fur c d - - ❑ ❑ ❑
Z, O w - License Class Li c.Number
Q z w Date- Contractor
¢ m 2 BUILDING PERMIT
I{ IS w ¢ OWNERdi UILDER DECLARA
ea MISC.- EFER TO ORD INFORMATION
K
3 LL y I hereby affirm that I am exempt from Dm Contractor's License VALUATION lI
r e. o J Law for the following reason.(Sec.7031.5;Business o
Bad Prfessions PERMIT ISSUANCE 6.00
Code:Anychy orcounty which requiresa permit t oconstrucLaller• ELEC.CONTR. LIC.NO. /
¢ e,a 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC. x
S, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A m he is licensed pursuant to the provisions of the Contractor's License -
aa Law(Chapter 9(commencing with Section 7000)of ivision 3 Of the
i ¢o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IS I- the basis for the alleged exemption.Any violation of Section 7031.$ TORIES TYPE CONSTR.
a3$ by of in. flat fora permit subjects theupplicaNtoucivil penalty ALTER-DRAIN -WATER (EA.) 4.00 4
of not more than five hundred dollars the applicant
.1:
❑ 1,as owner,of the property,or my employees with wagesas 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 '1`r,ECy/J�O/
Code: the Contractor's License Law does not apply to an owner rl'
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
\� himself or through his own employees.Provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 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 lc did not build or int-
i prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000 IND CON PR Omer
.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:*1 lie Contractor's license Law docs 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 contractons)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,17.&P.C.In,Ibis WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKLRS'COMPHNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate Uf consent to"If-insure,
or a cetlificme of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy tltereof(Suc.3800,Lab C.).
Policy ND. Company
O ❑ Certi heQcopy is hereby faerophed. FIRESPRINK ENERGY T-24
Z Z ❑ CcrAl ca Y i II wi Be it inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N Y ❑ N❑
~ H PERMIT ISSUANCE 6.00
LU ] C. IPICV NSATI I'T INSUROhf WORKERS' FL000 2OrvE aL.U.C.
W _ O PIiN$ATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (Phis section need not be completed if fin pennit is for one TOTAL v❑ N❑ Y ❑ N❑
D Z hundred dollar.,(S 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any munnerso as to
O wm
becoe subject to the Workers'Compensation Laws of Calfforlou
y Date- Applicant ALTER OR ADD TO MECH. 4.00 BUILDING �y�y 60
} in NOTICE TO APPLICANT: If,after making this Certificate of Ex. ✓l/
I__ ? 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(evoked, AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION L17NDING AGENCY AIRHANDLING UNIT(OVER 10pODQF.M.) 5.00 SEISMIC FEE
I hereby affirm that there is it 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read thfs,,ficition and stale that the abm'e V ENTILATION FAN ISINGLE) 3.00
information is correct. I agree to comply with ell city and county PLUMBING
ordinances and state laws relating to building construction, and
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon thea OILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection parposcs.
(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 aceI . •afnst said City In consequence of the
gundin this pet MECH.CONT, LIC.NO. MECH.
TOTAL
hulftforeof pic of/Contractor Date TOTAL s�
OFFICE COPY