4997 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOPING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING ^ APPLICATION & PERMIT
AOD s 1
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL - 4997
C.Ps'n S PLAN CH ECK VALIDATION
/ NAME 0 TV. ELECTRIC PERMIT FEE
c NT ACT s OUTLETS-SWITCHES-RECEP 5.00/1.00
�1
uc.N LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
PANELS - 5.00 o E PL nnoN
IARCHTTECT SIGNS 6.00 PLAN H K EE P.C.NO.
OR
ENGINEEIA�
uc.NO SIGNS TRANS. 3.00
ARCR'ESS ENG' SPECIAL CIRCUIT 5,00 PERMITVALID TION
zm ITEMP.METER OR POLE INS. 15.00 i
APPLICANTS MOTORS SEE FEE SCH.
A q
SERVICE CHANGE 10.00
-00 LICENSED CONTRACTORS DECLARATION
< it w '1 hereby affirm that I am licensed under provisions of Chapter I Z.�` -ISSUANCE DATE
to
Z.
�, (commencing with Section 7000)of Division 3 of the Basi an`I ELECT. PLG. .MECH.
r y i Professions Cod oA -nse ism fulljCQ �.-
i o L - Lmens Ia s Lic.Num he h
9 m r Date L El
Contractor
m � BUILDING PERMIT
¢ a OWNER-BUI LDER DECLARATION
ec ¢o a,o INFORMATION
E:
; LL y I'hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD
R ago J Law for the following reason.(See.703 L5,Business and Professions PERMIT ISSUANCE 6.00 `/^Lunn N /FT.
E w 0 Z Code:Any city or county which requiresa permit t0C0m ruVt,aIIeq ELEC.CONTE. LIC.NO.
re ¢ 4;O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
0 , reaches the applicant for such permit to Zile a Signed Statement that TOTAL pE
E:
a he Is licensed pursuant to the provisions of the Contractor's License
Fz >
Law(Chepter9(core mencing wit h Sect ion 7000)o f Division 3 of t he
s E o Business and Professions Code)or that he is ex staff therefrom and
¢ $ the basis for the alleged exemption.Any violation of Sect ion 7031.5 DTV. PLUMBING PERMIT FEE
5 RIES TYPE CONSTR.
d ; by:my applicant for a permit subjects the upplic,ut to it civil penalty - ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).)!
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 ocC.GR P RE .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. 4.00
Code:The Contractor's License Law does not apply to all owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTACREAGE
himself or through his own employees,provided that such improve.
menta are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
OF improvement is sold within Beoyear of completion;the owner
s builder will have the burden of proving that he did not build or jm- GAS"EA.SYSTEM-OVER 4 (EA.) 1.00 BUILOIN USE
prove for purpose of sale.). I INDUSTRIAL WASTE INTER, - 20.00 RES IND PB Omer
FJ 1,as owner,0t the property,an exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS S PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of prnperty who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts lihsuch projects with it contructons)licensed pursuant In SEWER-SANITARY-STORM EA.,200ft/8.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tum exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT _ 4.00
on
Duro owner- WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby aHirm (list I have u cerlileate o f consent toself-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensuti0n Insure ce,or a ceyll led
/ copy ih� . h.0 -F ,•/
Policy�il(OPJ
my
I�UnCJ_
Q ❑ 0171 'opy is Lerchy�rniahed' FIRE SPRINK ENERGY T24
Z Z/ rsdi CerII c is fd6V with h it yin diol rvi '
p� pv(cant MISC.- REFER TO ORD. Y N v ❑ N❑
~ to
LU CERTIFICATE COWIPSATION F EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Lu.C.
W � COMPENINSURANCE
URANCE PLG.CONTR. LIC.ND. PLG,
CL o (This section hued not he completed if the pertain is for one TOTAL Y❑ NY [:] NE]
Z) Z hundred dollars(S100)or less,)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H- mit is issued, I shall not employ any person in any manner so as In
Ow become subject tothe Workerv'Compensution Laws of California.
y Date Applicant _ ALTER OR ADD TO MECH. 4.00 BUILDINGlest
} N NOTICE TO APPLICANT: IL after making this Certificate of Fs-
HZ emption,you Should become subject to the Workers'Compensation APPLIANCE _ ' 4.00 PLAN CHECK
provisions of the Labor-Code, you Inter forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)o00GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm (list filen is a constmetion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perforriance 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 -
Icertifythatlhavereadthisapplicationandslatethalthcabove VENTILATION FAN (SINGLE) 3.00
information is .cornetI agree to comply with all city and county PLUMBING
ordinances and stale lows relating to budding confliction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4:00
hereby authorize representatives of this city to enter upon file
above-menfinned property for inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) ngrec to save, indemnify and keep list Its, the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments', costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
m any way ii��@p��rue agai said Ci in consequence of the
If gof lh is per Mil, -/6 MECH.CONT. LIC NO. MECH, c
to, 2 yOTAL TOTAL
Signature of Applicant/Contractor -Dae
OFFICE COPY