4503 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aUILDING APPLICATION & PERMIT
o DRESS
• I A _ E �� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 4503
WNER's PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ele
ONE
CO TFACJOAHS
NAME �-+�`' Fl `��� Q�/ OUTLETS-SWITCHES-RECEP 5.00/1,00
LIC.NO. _ LIGHTING FIXTURES 5,00/1.00
CON
ADDRESS' 7,- 'q���./� APPLIANCES-RESIDENTIAL 4.00
f
_ PANELS 5.00 DATE OF APPLICATION
ARCHITCTSIGNS 6.QQ PLAN CHECK FEE PC.NO.
OR
T" LIC.NO. SIGNS TRANS. 3.00
ADDRESS era. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
L<T zIv TEMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH, e/
ADDDREDRESSS
�{/•� ft / SERVICE CHANGE 10.00
,02 LICENSED CONTRACTORS DECLARATION I T
3 U u I hereby affirm that I am licensed under provisions Of Chapter 9 ISSUANCE PATE
N < H (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
H H z Professions Code,:_ ense,is in full for
Z 0 F W License[ass_ Lit.NumberCg
Date Contracto
a m ¢ a OWNER-BUILDER Df ARATION - BUILDING PERMIT
c 0 w U MIS[.- R TO OR INFORMATION
w ; I- I hereby affirm that I am exempt from the Contractor's License
VALUATION $/FT.
F .. o¢ Law for the following reason.(Sec.70J L5,Business and Professions PERMIT ISSUANCE 6.00
Code'.Any city or county which requires a permit to construct,alter,
ac A Q FO improve,demolish,or repair any structure,prior to its issuance.also EL CONTR. LIC.NO.L� LEC.
A c¢ requires the applicant for such permit to file a signed statement that C L TOTAL ��,� PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
r i i
Law(Chapter 9(commencing with Section 7000)cfDivision 3 of the - ELr e-/
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE-:
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant o a civilpenalty ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred dollars 1$5001.1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC,GROUP RES.UNITS
their sole compensation,will On the work,and the structure is not
• intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
ourmsarenotintendedorofferedforsale.If.however.the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Other
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISee, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts far such projects with a cuntractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
eason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING or a certificatethof Workers'Compensation � W ENG.SITE NO.
Copy the e 1 e .C.l.
Po l' ny
Z Cerll e copy is hereby turn had. FIRE$PRINK ENERGY T2
p Certified <o city ins tial ivision.
AffIp11-cunt REFER TO ORD,
Z 0 � // MISC.- Y ❑ N❑ Y ❑ N❑
N CERTI' ATE OF EXEMPTION FR6.M WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
1 Y❑ NO ; v ❑ NN[_0 (This section need not be completed if the permit is for one TOTAL
::) 2 hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEESUMMdRY
LL F mit is issued, I shall not employ any person in any manner so as to
U become subject to the WorkersCompensation Laws of California.
0 UD i Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
}
0 NOTICE TO APPLICANT: If.after making this Certificate of Ex
� z emption,you should became 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 revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.15.00 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 wla h this permit is issued(Sec. MICROFILM
3097.Civ.C.), ��Oy� HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC ,) C
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4,00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs mW expenses which CONST.TAX
may in any way accrue again. in consequence u'the PERMIT ISSUANCE 3.00
gmnting.of Is MECH.CONT. LIC.NO. MECR.
% t AL TOTAL
.on
a pplicant Co ractor Uate
OFFICE COPY