14043 T
APPLICANT TO FILL IN INFOP ATION WITHIN RED LINES — USE I.L POINT PEN ONLY
BUI LDI NG PROJECT IDENTI FICA PERMIT NUMBER
BUILDING APPLICATION & PEWT
ADDRESS 90 ��1S ,.iei� �3 0 � � 14043
�(] [,6�r� rt.— BUILDING — ELECTRICAL—PLUMBING —MECHANICAL
NAME SAA_ $OV PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR' OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC,No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S - APPLIANCES-RESIDENTIAL 4.00
ADDR ES
PHONE PANELS 10,00 DATE OF APPLICATION
RcrrtsCT - PANELS (OVER 200 AMP) 20.60 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,66 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 q -
AMOTORS - SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20.00 ��
w 0 o_ LICENSED CONTRACTORS DECLARATION �/1
c it Thereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
<i (commencing with Section 7000)of Division 3 of the Business and BLDG, ELECT. PLG. MECH.
r D Z Professions Code,and my license is in full force and effect. E] ❑ ElO 0 =W License Class Lic,Number
Dale Contractor
Y I BUILDING PERMIT
Ix w a OWNER.BUILDER DECLARATION INFORMATION
CAU MISC.— REFER TO ORD
E
g;a. G 1 hereby affirm that I am exempt from the Contractor's License VALUATION
HU0< Law forthefollowiagreasoo.(Sce.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
a ¢¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC:NO. ELEC.
it
G, requires the applicant for such permit to file a signed statement that TOTAL
u PERMIT TO
Er
m he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe L� /
4 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE (J�
rz I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mon than five hundred dollars(S5001):
❑ [,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 0 FIXTURES-PER TRAP 5.0010 SO.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.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 int- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project fSec.7044,Business LAWN SPRINKLERS-1 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Contractor's License Low.
contracts for such projects with a contractor(s)licensed pursuant a
the SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
C
❑ Icon exempt under Sec. ,B.&P.C.fur this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM IMI i L'upelD5l00 Ace,DATE Ace,FILE No.
WORKIi 5'COMPI'm PION DECLARATION WATER TREATING EQUIP- 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company -
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with lie MISC,- REFER TO OR
city inspection division.
O Applicant Y ❑ N Y ❑ N❑
d' w CERTIFICATE OF L'XEMPI'[ON FROM WORKERS' PERMIT ISSUANCE 10.00 ��,4s FLOOD ZONE A.L.U.C.
W AT
� COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V
CL Z (This section need not be completed if the permit is for one TOTAL V❑ N❑ Y[3 N❑
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 FEE SUMMARY
LL F out is issued, I shall not employ any person in any manner so as to
LYbecome subject to the Workers Compensation Laws of California.
U,
Date—Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE 1'0 APPLICANT: II,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
. I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 crCivC ante of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Leader's Address ELECTRIC C�
1 certify that I have read this application and state that 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-DOW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property lot 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 in any Iy ay ace e-against said City in conseyuence of the PERMIT ISSUANCE 10.00
granting Of CRs rtri MECH.CONT. LIC.NO. MECH.
coT
TOTAL TOTAL
Sig to o Applicant/ onlracfor Date
OFFICE COPY