11364 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION, PERMIT NUMBER
\ , BUILDING APPLICATION & PERMIT
' ^ A �^ A
X aooREs _ - I I b
5hEzL)eqPz P" BUILDING -ELECTRICAL-PLUMBING MECHANICAL 4
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OWNER'a PLAN CHECK VALIDATION
NAV
e OTY. ELECTRIC PERMIT FEE
- I
Ile PHONE
cONTRac*oRs - UTLElI SWITCHES-RECEP 10.00/1.00 '
N N
uc.No. LIGHTING FIXTURES10.00/1.00
TRACTOR'S APPLIANCES-'RESIDENTIAL 4.00
ADDRESS
PHONE PANELS •10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK'FEE P.C.NO.
OR
_ ENGINEER
LIC.No. SIGNS TRANS. 3.00
A OORESS ENa. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zap TEMP..METER OR POLE INS. 20.00 I
APPLICANTS MOTORS .SEE FEE SCH.
AOOREss l..Q
- - SERVICE CHANGE 20.00 � r 4- l
a o LICENSED CONTRACTORS DECLARATION - I I ��
a i w I hereby affirm that 1 am licensed tinder,provisions of Chapter 9 ISSUANCE DATE
(commencing Willi Section 7000)of Division 3 of the Business and sl BLDG. ELECT. PLG. MECH.
N i Professions Code,and my license is in full force and effect. N I,I!C ❑ ❑ ❑
oi w o License Class Lia Number
,�H Date Contractor
< > 2 � Cu ertin BUILDING PERMIT
rc w OWNER-BUILD17R DECLARATION - INFORMATION
O A MISC.- REFER TO ORD
Is ;u. w I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
HLLOJ Law for the ity Or coreason.(Sec.703L5,ermBusiness t tocand Professions 'PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit toconstruct,alter,
R rR improve,demolish,Or repair any structure,Prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G , requires the applicant for such Permit to file a signed statement that TOTAL s3 Q.i PERMIT TO
w ro he is licensed pursuant m the provisions of the CoNrnctor's License Le�7
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe E
f 4 c Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
Ie r m the basisforthe alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).);
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 • OCC.GROUP RES.UNITS
their axle compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
»ty Code:The Contractor's License Law does not apply to an owner of
j' property who builds or improves thereon,and who does such work FIXTURES-PER TRAP' 5.00 - SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsMenotintendedorofferedforsale.If,however,the building GAS-EA,SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ire.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON, PB Other
❑ as owner of the property, exclusively contracting with 1:1 - El El •❑ 1:1
licensed
contractors to construct the
project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Lew docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects Willi a contractors)licensed pursuant to $EWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt Under Sec. _,B.&I-k.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPE ATION DECLARATION ' WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure. - .ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No.' Company -
0 ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T-YO
Z 2 ❑- Certified copy is filed with the city inspection division. MISC.- REFER TO ORD:
O Applicant V ❑ N V L] NE]
' CERTIFICATE OF EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE 'A.L.O.C.
LU J COhIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0 (This section need not be completed if the permit is for one ITOTAL Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or Icss.)
U O 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. _
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of lix-
I'- ? 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
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is'a construction lending agency for EXHAUST HOOD(WITH DUCT) .5.00 -
the 3097rCt)nce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
,Civ
Lender's Name HEATINI (OVER 1000 BT
NG UT E00, . .U.)9.50
Lender's AAdres's - 3
ELECTRIC 0 '�
1 certify that I haveread this application and state that the above VENTILATION FAN (SINGLE) 4.00
m
inforation statc correct
1 agree to comply wish acity and county PLUMBING
ordinances and stale laws.relating to building construction, and BOILER,COW(3 H.P.Or 100,0006.T.U.) 6.00
/ hereby entioned representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
\\
hereby
property forinspefth i purposes.
(We) agree m save, indemnify and ep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgment, Stsand expenses which - CONST.TAX
may in a ay accrue against vid'Cit consequence of the PERMIT ISSUANCE 10,00
loot' this pe MECH.CONT. - LIC.NO. MECH.
_ TOTAL TOTAL
Slignature of Ap icant onlruoo ate '-
OFFICE COPY