4447 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
9UAPPLICATION & PERMIT
. r�
a
DREs1
Sf PTfm D BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
91 NAME r')-�'/-��+ CITY. ELECTRIC PERMIT FEE
DDA 19 �D[ /r PHONE 3IYOr�
NAMERADTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC,NO, LR3HTI NG F IXTURES 5.00/1.00
Ac7oRs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
OR
SIGNS 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
sec,NO. SIGNS TRANS. 3.00 '
ADDRESS eNc, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICECHANGE 10.00 /O�p
O 0 LICIiNSED CONTRACTORS DECLARATION p S V 0
Pc �( I hereby affirm that I nm licensed under provisions of Chupler 9 ISSUANCE DATE
n¢w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w ¢ Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
z O m - License Class Lic.Nunther-a � �_ 'Date Contractor- R Oe� �'p�z p..8
x i 3 BUILDING PERMIT
¢ ao n u OWNER-BUILDER DECLARATION INFORMATION
E:
I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION
Hu0J Law for tire following mason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 $)FT.
N'A Code:Anycity orcounty which requires a permit to construct.alter,
4 1 p' y rior to its issuance,also ELEC.CONTR. LIC.NO.
rt ¢ ¢ O int trove,demolish,or repair an structure,p ELEC. 7
Q rC thon,the applicant for such permit t0 file a signed statement that TOTAL
u w se he is licensed pursuant to the provisions of the Contractors License PERMIT TO
FiQ
Law(Chapter 9(colnmencingwitlt Section 7000)of[ ivisinn 3 of the
4 o Business and Professions Code)or that he is exempt lherefrmn and DTV. PLUMBING PERMIT FEE
¢ 1- $ the basis lbrtlmalleged exemption.Any violation of Section703L5 STORIES TYPE CONSTR.
i 3 - by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars 135001.):
❑ 1,as owner of the property,or my employees with wages as BACKFLOW 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 ly
IpQL \
Code:The Contractor's License Law dues not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00, SO.FT.FLOOR AREA TOTAL ACREAGE
himself or.through his own employees,Provided that such improve- _
ments in not intended or offered for sale.It,however,the building GAS-EA.SYSTEM-1 INC.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 he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. RES IND CON PR Othe,
❑ 1,as owner of the property,ant exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business ILAWN 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 builds or improves thereon,and will) LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractorw licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl I am exempt under Sec.-,B&P.C.for this WATER HEATER 111 4,00
reason
Date 10 .7 Ow WATER SYSTEM 4.00
� ACC.DATE ACC.FILE N0.
WORKERS'CO.MPENSATION D17CLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a ceAficam nl consent to Self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sao 3800.Lab,C.).
Policy No. Company
.O ❑ 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.
O Applicant Y ❑. NO Y ❑ NO
~ CGRTIICEXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A.L.0 c.
W > CONIPFNAIION INSURANCE
PLG.CONTR. LIC.No, PLG.
0' Cl (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that m the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H ntit is issued,I shall not employ any person in any manner so as to
-
U become subject to the Workers'Compensation Laws of California
0 y Date Applicant BUILDING 'If
} m NOTICE TO APPLICAN"I': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
F ? cmption,you should become subject to the Workers'Contpensition 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 AIR HANDLING UNIT(OVER I0)000C.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,Civ.C.). 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 I have read this application and stale Brat Bne above VENTILATION FAN (SINGLE) 3.00
in'
m
oration is correct. I agree 10 comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-fbMP(3 H.P.or 100,000 B.T.U.1 4.00
)hereby authorize representatives of Ihib city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
ioi
(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 CONST.TAX
may in any Way accrue against mid City in consequence of the 3.00
gmnY fit permit MECH.CONT. LIC.NO. MECH.
I -IllTOTAL TOTAL 5
Signature of Ap ^fic / `�-
OFFICE COPY