11479 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P.;;;ti OIN'LY
BU I LDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT A w n^
AOORESE I I r y
I BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NnME GTY. ELECTRIC PERMIT FEE
r Co C PHONE Cl L( ^19 L3
coNTRncroR's
NOUTLETS-SWITCHES-RECEP 10.00/1.00
AME
r Car Ic.No. 3� 7 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADORE �
PPLIANCES-RESIDENTIAL 4.00
ab� Sipvelc rPRONEp
^ I PANELS 10.00 - DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLANCHECKFEE P.C.NO.
OR
ENGINEER
LIC.NO ISIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 500 PER MIT VALI DATION
ADDRESS .
ZIP TEMP.METER OR POLE INS. 20.00 _ )
APPLICANT'S MOTORS SEE FEE SCH. _/IlA_"'i7Aw-�
ADDRESS
SERVICECHANGE 20,00
0 0 o LICENSED CONTRACTORS DECLARATION
< v U I hereby affirm that I me licensed under provisions of Chapter 9 ISSUANCE DATE
in< N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Code d my license is in full fore fete. a _ '} J�"i' ❑ El 11 ❑
2 o m- License ass Con Numbe rL
9 F Dole Contractor_
ettin BUILDING PERMIT .
a w st OWNER-BUILDER DECLARATION INFORMATION
oA MISC.- RTO ORD
X 3 u. H I hereby collo that I am exempt from the mess actors License VALUATION
u 0¢ Law for the following reason.(See.703 L5,Business and Professions PERMIT ISSUANCE 10.00
i - Code:Any city or county which requiresa permit louonstmct,ulter, O
Ina c O improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u c LL requires the applicant for such permit to file a signed statement that TOTAL 30 PERMIT TO
he is licensed pursuant to the provisions of lire Conlmctor's License
FZQ Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe �Gr� n doe L`y
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEEJ-
tC IT-$ the basis for the alleged exemption.Any violation of Section7031.5 STORIES TYPE CONSTR.
n 3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4,00 OCG.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
properly 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 nommye.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ire- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pB Omer
❑ I,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 contruclods)licensed pursuanl to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt Under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACG.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DIzCLARA'I'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lah.C.l.f 6R
Policy Nn. Company — C�
0 �❑/ Certified copy is hereby furnished.' FIRE SPRINK ENERGY T-24
Z Z yK Certified copy is filed with the ciry inspection division.
O 711 MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
A p Cunt Y N V N
= W CERTIFICATIi OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1 10.00 FLOOD ZONE A.L.U.O.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C' o (Phis section need not be completed if(lie permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars($100)or less.)
U 0 1 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 manner so us to
U become subject to the Workers'Compensation Laws of California.
Date A lieant BUILDING
So 7P ALTER OR ADD TO MECH. 5.00
} to NOTICE prion TO APPLICANT: If,after making this Certificate sa Ex-
emption, tire Labor
to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions io the Labor Cit sir you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0000 F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE
I hereby affirm first there is a constriction Lmiog agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3 O",CRC.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 3U tl�
Lender's Address ELECTRIC I C
I certify that I have read this application and slate Ilia[the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
' ordinances and state laws relating to building Construction, and BOILER-COW(3H.P.or1O0,000B.T.U.) 6.00
hereby authorize representatives Of this city to enter upon the BOILER-COMP (Over 100,000 BTU)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
By in any way acer against said City in consequence of the
gra ngofth'spennil I -/ MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
MKITfuire of Applicant/Contra D le
OFFICE COPY