0631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0631
A111/c1/Sa 5. STE�Iln�S fW BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
sxJ PLAN CHECK VALIDATION
-� N/,ME%Rg QTY. ''I 7f ELECTRIC PERMIT 6 t' a FEE.,i.
It 'x/,C/lJ� PNONE v -I>/ ) �4 1i$.: r (.t�, A �'-3r,1
•.
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
OTORS PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHELK FEE P.C.NO,
OR
ENGINEER 3.00
LIC.rvo. SIGNS TRANS.
AARCH OR
DDRESS ENG SPECIAL a 5.00 PERMIT VALIDATION
tffLZIP TEMP. OR POLE I 15.00 ^
APPLICANTS MOTORS
EE FEE SCH. (J�/tea
ADDRESSSERVICECHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION 7// /
Mu[s 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n a w (commencing with Section 7000)of Division 3 of the Business and _-_G 7-ELECTT PLG. I MECH.
r i Professions Code,and my license is in full force and effect. ❑ El
Z:D License ClassLic.Number
Date Contractor
xa _BUILDING'PERMIT.
< OWNER-BUILDER DECLARATIONINFORMAT10N
¢ w u +:".,''.:.{i. 5,it}aS
o A. REFER TO ORD
I- I hereby affirm that 1 em exempt from the Contractor's License MISC.-
3 VALUATION S/FT.
uo< Law for the ity orcounlson.(Srequirsa Demsit to construct,
Professions PERMIT ISSUANCE 6.00
G
Code:Any molish.ounpair any structurep prior
tmconsuancalter,
c i p improve,demolish,or repair any structure,prior n its issuance,also EL C.CONTR. LIC.N0. ELEC. /
wesu requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
An,^ he is licensed pursuant to the provisions of the Contractors License
> Law(Chapter 9(commencing with Section 7000)orDivision 3 of the
Fi o Business and Professions Code)or that he is exempt therefrom and OTY-'mrs�sHd.g�PLUM8ING'PERMIT) >-�x' FEE , F
¢ the basis for alleged exemption.Any violation of Section 7031 5 xn,.._. 7_ ,f STORIES TYPE CONSTR.
by any applicant forapermit subjectsthe applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the atmcturc 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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mens are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4,00
I. 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. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,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 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 contractor(s)licensed pursuant m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Con
reaso❑It I am exempt under Sac.-,BAP.C.for this WATER HEATER W/VENT 4.00
\JC
Date Own,• WATER SYSTEM 4.00 ACC.DATE ALL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y E) N❑ Y ❑ N❑
~ m PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� CERTIFICATEONSATIOTINS FROM WORKERS'
CL COMPENSATION completed
if the PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
CL Z hundred
section need not be c°mplcled if the permit is for one TOTAL
hundred dollars(S100)or less.)
U O I certify that in the performance of the work for which this per- OTY. - MECHANICAL PERMIT FEE FEE SUMMARY.,,,'1
IL F mit is issued,I shall not employ any person in any manner w as to
U become subject to the Workers'Compensation Laws of Califomia.
O w Date-Applicant BUILDING
>_ N NOTICE TO APPLICNT:If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
F 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
5 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000C.F.NL) 5.00 SEISMIC FEE a $?J
I hereby affirm that there is a construction lending agency Our 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 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all nsand county -PLUMBING.,
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 4.00
r hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposeS. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may inan way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gra o of his per�1 MECH.CONT. LIC.NO. MECH. _
'.� �(cl�sov✓ 1 TOTAL TOTALy^' S�
Ignatureof Applicant/Contractor Date
OFFICE COPY