4956 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
So LOING APPLICATION & PERMIT 4 9 5 6
ADD&Ess ;�`_ 1� / ���'1I
Vy� SITVi4S(`Y<2 \ll BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNR'S ' PLAN CHECK VALIDATION
NoxIsE 'A. CITY. ELECTRIC PERMIT FEE'
W ;�1 i q Uh Q rucc7JDNE
CONTRACTORS ` OUTLETS-SWITCHES-RECEP 5.00/1.00
ME V.J.•-�
T `
Llc.rvo. LIGHTING FIXTURES 5.00/1.00
f«.trG a
AO REACTORS �'G/� APPLIANCES-RESIDENTIAL 4.00
�� er+Jr� µPRONE
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
EN
ENGINEE �/
T uc.No. SIGNS TRANS. 3.00
ORc".oR Ery ,S. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
AOORsss .y77 �qy,H w.
EMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
a it 1 hereby affirm that 1 am licensed under provisions of Chapter 9V1. ISSUANC [ANTE
y¢ i (commencing with Section 7000)of Division 3 of the Business and pG. ELECT. PLG. MECH.
r y Professions Coadd nd �ye�I s hill for f
License assC' �' 7L1c� 'f0
Q " w- Dale Cont
a x f BUILDING IYERMIT
(paw ¢ OWNER-BUILDER DECLARATION INFORMATION
w0 a MISC.- REFER TO ORD
°y I hereby affirm that I am exempt from the Contractor's License
.. oea Law forthe following reason. 7031.5.Business and Professions PERMIT ISSUANCE VALUATION
� - Code:Any city or county which requiresu permit to construct.alter. 6.00
IS ¢Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ic
O urequires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the 0 of Contractor's Li ense
i t Law(Chapter and
Professions
de)or Section is exempt ion
o of the ,.} '
¢ Business and Professions Code)or that he is exempt therefrom and DTV.' -� ' ' PLUMBING-PERMIT ( -`FEE'
¢ she basis for[he alleged exemption.Any violation ofSection malty .e =. ,c '.." _ ..
STORIES TYPE CONSTR.
i ; � by any applicant fora permit subjects the applicant loacivil penalty ALTER-DRAIN -WATER(EA.) 4.00
of not more than five hundred dollars 155007.1:
❑ 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 structure is not
intended or offered for sale(Sec. 7044. Busmess and Professions 3 DRAINS-FLOOR,ROOF,AR EA,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 F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,she 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 IEA.) 1,00 euapw USE builder will have the burden of proving that he did not build or im- RES AlB Omer
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ 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. 5.00 l So RCE,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 IEA.) 1.00
contracts for such projects with a cntructoris)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL No.
❑ lam exempt under Sec.-,B STC.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certilicase of consent to self-insure. ZONING ENG.SITE NO,
or a tertifica[e oo f('Workerjs,�Cam ensasion Insurance,or a carotic
copy sdR`)'ss�'-'J--r��rslDFa.C. . r
Policy ny I.
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z
17 Certl is Ity inspection division. MISC.
REFER TO ORD.
O APPlican� c Y ❑ N❑ Y ❑ N❑
c rn CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00W - FLOODZONE ALU.C.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 'jaw
n' D (This section need not be Completed If the permit IS for one TOTAL`) O Y E3 IN V ❑ N1
D Z hundred dollars IS 100)or less.) '> I. t. .
U O I certify that in the performance of the work for which this per QTY., 1's 4t - M�ECHANICAL�PERMIT'T- -FEE , FEE SUMMARY-
LL H mit is issued, I shall not employ any person in any manner so as to c :°,
U become subject to the Workers'Compensation Laws of California.
w Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} m NOTICE TO APPLICANT. If,after making this Certificate of Ex.
L.. Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you muss forthwith comply with FEE
U 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 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
she 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 Ndame
Lenders Adress
HEATING UNITIOVER 100,000B.T.U.P.50 ELECTRIC
I certify that I have read this application and state that she above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U) 4.00 PLUMBING 1' Ll 0�
ordinances and state laws relating to building construction. 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 she City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of she
grand - _ MECH.CONT, LIC.NO. MECH, •-
\/ _l OTAL TOTAL,'`. .
1`
Signature of Applicant/Conlramor Date
OFFICE COPY