3611 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
WALD ING PROJECT I DENTI FIr 'ON PERMIT NUMBER
^UILQING APPLICATION & PEAAIT 3 611
Ogg ESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
.NE 'S• PLAN CHECK VALIDATION� QTY. ELECTRIC PERMIT - .',FEE;
v orvE
CON ACTORS
NA ,ayyOUTLETS-SWITCHES-RECEP 5.00/1.00
O uc.rvo U LIGHTING FIXTURES 5.00/1.00
T aTo ! APPLIANCES-RESIDENTIAL 4.00
PRONPANELS 5.00 DATE OF APPLICATION
AR HIT CT
OR SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.rvO.
AENG, SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP TEMP. METER OR POLE INS. 15.00
FilsN MOTORS SEE FEE SCH,
•
I.o o SERVICE CHANGE 10.00 LICENSED CONTRACTORS DECLARATION
A u N I hereby affirm [hut 1 um licensed under provisions of Chaptcr 9 IS&U 'NCE DATE
Nay (commencing with Section 70001 of Division 3 of the Business 4 d
ti H 2 Professions Co an y license is in full Inrce' BLDG. ELECT, PLG. MECH.
z o m - License Class" .Number ❑ ❑ ❑
4 5 o Date -ontractor
/6 111
rc ¢w <- OWN UILE)u DECLARATION BUILDING PERMIT
w ;A. I 1 hereby affirm that I am exempt tram the Contractor,LicenseMCONTR
=ISSUANCE
TO ORD INFORMATION
LL o 4 Law for the following reason.IScc.7031,5.Businessand Professions VALUATION
t - SIFT'
Code:Any'coy0rcounty which requires a permit m coissuanc ,also6.00
¢ ¢ ¢ improve,demolish,or repair any s[rucnne,prior to its issuance,also LIC.NO.
D
n L¢ requires the applicant for such permit to file a signed statement that TOTAw m w he is licensed pursuant to the provisions of the Contractor's License PERMIT T
HiQ Law(Chapter 9(commencingwitli Section 7000)ol'Division 3 of the
i G Business and Professions Code)or that he is exempt therefrom andEBACK
PLUMBING PERMIT FEE
¢ 5 S the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a � by any applicant fora permit subjects the applicant is am too civil penaltyAIN& VENT-WATER (EA.) 4.00
of not more dant five hundred dollars 155001.1:
❑ 1,as owner of the property,or my employees with wages asW PROTECT.DEVICEtheir sole compensation,will do the work,and the structure[s not 2.00 DCC.GROUP RES,UNITS
intended or offered for sale (Sec. 7044. Business and ProfessionsLOOR,ROOF,AREA,COND. 4.00
rode:The Contractor's License Law does not apply to un owner ofproperty who builds or improves thereon,and who does such work -PER TRAP 4.00 SD,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
merits are not intended or offered for sale.ll',however,the building GAS-EA,SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1,00 BUILDING USE
prove 1.as ownerose
of sale.p INDUSTRIAL WASTE INTER. RES IND CON Pe Omer
❑ L as owner of the property,am exclusively contracting with 20.00 13 ❑ ❑ ❑ ❑
licensed contractors to coretruct the project(Sec. ]044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00
and Professions Code:The Contractors License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such promos with a contructorlsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4.00
ACO.DATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby utfirm that I have a certificate. consent to self-in is,
or a certificate of Workers'Compensation Inn care
or a cer lied ZONING ENG.SITE NO.
copy Cher 00,Lab.C.1.
P01icyN Company_
O Ce riliedcopy ishereb rnis FIRE$PRINK ENERGY T30
Z Z Certifed rs f d it t city inspection division.
A 'cant MISC.- REFER TO ORD. Y C] N V Is
~ O � � PERMIT ISSUANCE
H CE IIRIF 'EXFiM ION FROM WORKERS' 6.00 FL000 zoNE A.
L COMPFNSATION INSURANCE PLG.CONTR, LIC.N0. PLG.
CL O (This section need not be completed if the permit is for ane TOTAL Y❑ N[] Y ry�
Z hundred dullmsfS1000or less.)
U O I certify that in the performance of the work for which this per DTV MECHANICAL PERM( FEE FEE SUMMARY
L F mit is issued, I shall not employ any person in any mannerso as tD
U become subject to the Workers Compensation Laws of California.
UJ Date Applicant ALTER OR ADD TO MECH. q,00 BUILDING
>_ to NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
I- Z emption,you should become subject to the Workers'Compensation APPLIANCEC' 4.00 PLAN CHECK
U
provisions
hpnrvisi onthe
or tl Labor
hall comply with be deemed revoked.
AIR HANDLING UNIT(TO IQ000C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVE • CMW , SEISMIC FEE
I hereby affirm that there is a cons conn lending agency for EXHAUST HOOD (WITH CT) 2.00
the performance he work f r whi his pe mit i issued(Sec. MICROFILM
3097,C'i HEATING UNIT(TO 100.000 B.T.U.) 4.00
Lenders Nam Name _ �, HEATING UNIT 100, . . . .
000 BTU )750
Lender's Addres ELECTRIC
• Icertify tha Brea [sap seationandslatethuttheubove VENTILATION FAN (SI 3.00
information is correct. I agree (0 comply with all city and county'
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 4.0
UMBING
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. 801 LER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save., indem d keep harmless the City of MISC.- REFER TO ORD. - r
Cupertino against liabilities, dg nts, costs and expenses which CONST.TAX
may in y waY c e inaid City in consequence of the PERMIT ISSUANCE 3.00
gr g f this r CM.CONT. LIC.NO. MECH.
orA J ' TOTAL
'
LOT of pelican[/Contractor Date �J 5
OFFICE COPY