2540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FIC/ ''N rt[r ITER
BUILDING APPLICATION & PE IT
2540AD
DRESS
oZQ �aySC�F/EZ1� (�� BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNERS =.'= i3 ,':� ' PLAN CHECK VALIDATION
NAME {J Az ']J '1�ELECTRIC PERMIT _ FEE
4A� 1 � ONE - /JS i^h ._ • ��'�r
CONTRACTOR 5UTLETS-SWITCHES•RECEP 5.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER 3.00
uc.rvo. SIGNS TRANS.
ARCH, PERMIT VALIDATION
OR ENG. 5.00ADDRESS SPECIAL CIRCUIT
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICA T6 MOTORS SEE FEE SCH. /�✓J
SERVICE CHANGE 10.00
.00 LICENSED CONTRACTORS DECLARATION PAID
U is I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
P,a a (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code,and my license is in full force and effect. ❑
0'vs' 0 License ClassLic.Number
IA H J DEl
ale Contractor
m¢ a OWNER-BUILDER DECLARATION BUILDING P,ERMIT�%i,N=
¢W u CORD ".¢3.,. INFORMATION'v';-__1
LL H I hereby affirm that 1 am exempt from the Contractor s License MISC.- V Ayyn 1 ry� S/FT.
w 0 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 r �{�•
Code:Any city or county which requiresa permit toconslruct.alter.
Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. r
Er o LL requires the applicant for such permit to file a signed statement that TOTAL I P- M 'I
w$ he is licensed pursuant to the provisions.(the Contractor's License .. )
Uzi Law(Chapter 9(commencing with Section 70001 of Division 3 ofthe ;cn 4Ss.� S� . [.;:..Tti -+ti ' ' Y r .«I - ' k
z o Business and Professions Code)or that he is exempt therefrom and CITY.;c;.+IT -�' l,PLUMBING PERMIT �J ,{.t: .r, k,.FEE.r,
¢ r the basis for the alleged exemption.Any violation of Section 7031 5 -u"3"•� itf. "..''1:`a x4l"13f{.''a='•'Ds'" Yr v ( sY - }c:, Y E CONSTR.
i ; ,. by any applicant for a permit subjects the applicant to a civil penalty - U�y�� '`���
of t more than five hundred dollars(S3000:
ALTER-DRAIN -WATER (EA.)
XI,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 DCC.GROUP RES.UNITS
i,air 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 SD.FT.FLOOR AREA TOTAL ACREAGE
-'� himself or throughnot
own employees,provided If,however.
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
menta art not intended or thinofferedon for sale.If,however,the building
or improvement is mid 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 PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ ],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. 5.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or'unproves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a comraclor(s)licensed pursuant to
the Contractor's License Law. �.,.� "��� SEWER-SANITARY-STORM EA.200ft/6.00 TRACT N0. PARCEL NO.
❑ IamexemPlundcr Sec.=�(,L.L�.B.&P.C.for skis WATER HEATER W/VENT 4.00
In Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DEC'ARATI N WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate Ofecnsent to self-insure.
ZONING ENG.SITE NO.
ar a certificate of Workers'Compensation Insurance,or a certified
copy thereof l Sec.3800,Lsb.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y❑ N❑ v ❑ NC]0 Applicant
~ - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
fl CERTIFICATE OF EXEMPTION FROM WORKERS'
W �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ No
C e !This section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.) - x
f> 0 I certify that in the performance of the work for which this per. FEE SUMMARY 1 i
F mit is issued,1 shall not employ any person in any manner so as to CITU. MECHANICAL PERMIT, FEE t`^
LL U become subject to the Workers'Compensation Laws of California 'r•t f"`` f
0 0. Date Applicant ALTER OR ADD TO MECH 4.00 BUILDING �,,,� ..I
>- N NOTICE TO APPLICANT: If,after making this Certificate of Lx-
z emplion.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO t0,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.6M) 5.00 SEISMIC FEE
1 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.). H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT IO VER 100,000 B.T.U.17.50 /�
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building all
construction.and co and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 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 whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grantingofthis permit MECH.CONT. LIC.NO. MECH,
//) i TOTAL
�L,( e 2�-S' .TOTAL'S: .;
'i na(ureof Applicant/Contractor Date +".✓ ^
1
OFFICE COPY
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