2314 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL- POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT Nu RE
BUILDING APPLICATION & PERMIT n
ADDRESS `r
L1 M ' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
wNER3 - o - t PLAN CHECK VALIDATION
NAME DTV. i- -ELECTRICPERMIT FEE. .'
DoNTERAcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
COAOORESS NTRACTORS APPLIANCES RESIDENTIAL 4.00
��.YY1pYxT - -
PHON PANELS 5.00 DATE OF APPLICATION
on SIGNS SIGNS 600 PLAN CHECK FEE P.C.NO.
ENGINEER 1^
:JH LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 6,00 PERMIT VALIDATION
e. ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
a ¢ i
r o D LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
H O z Professions Co e,and my license is in full for• and effect ❑ ❑ ❑ ❑
2 0,� - Licetl)Yp Class Co ract.Numb
V
9 u w Dare Contractor f_t_ G
a Se s ^�'C•IQCS „BUILDINGPERMITty,J,,-
¢ ¢ a OWNER-BUILDER DECLARATION , M.•F�4
c A. U INFORMATION��.�.!
'x ; I hereby affirm that I am exempt from the Contractor's License MISC.- s E.IF TO ORD
N
FLL O a Law for the following reason.(Sec.7031.$,Business and Professions PERMIT ISSUANC VALUATION S/FT:
Code:Any city or county which requires permit to construct,alter, 6.00
IF ¢< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. CEL.
w-O 0 require,the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
Fri Law(Chapter 9(commencing with Section 7000)uf Division 3 Ofthe
¢c Business and Professions Code)or that he is exempt therefrom and OTY'. 3 w' (',PLUMBING PERMIT:y FEE;..
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.51..u53i 'w°-a i ,.e .-�r.3 --v it r..,I. s. at..,. ", -' i! STORIES TYPE CONSTR.
i ; _ by any more
five permit subject, S500).licant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more Than five hundred dollars 65001.1:
❑ 1,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. Business and Professions DRAINS-FLOOR,ROOF,AREA,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 FIXTURES-PER TRAP 4.00 SQ FT,FLOOR AREA TOTAL ACREAGE
menta are through his own employees,Provided that such int building
Or improvemnotent
is Sold within
forsale..I complever,tion the the ow Eng GAS-EA.SYSTEM-1INC.4OUTLETS 4,00
or builder
will have
is sold within One year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving than he did not build or int- RES IND CON PB Omer
P,-Y-Ie as ownerr purpose of the.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARLEL NO.
and Professions Code:The Contractor's License Law dues 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 contractom s)licensed pursuant 10
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
WORK ERS'COAIPEMATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is riled with the city inspection division. MISC- REFER TO ORD.
I"' O Applicant - Y❑ N111 Y ❑ N❑
rn W PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CERTIFICATE EXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE the PLG.CONTR. LIC.NO. PLGCL , Y❑ N❑ Y❑ N❑
Z (This doll... need not be completed if the permit is for one TOTAL
hundred aolmrd 181001 or le,,.) SAS•elv s ,',R ,; .U,,P 'AA.-r,3r ,
0 O 1 certify that in the performance of the work for which this per- OTr ad } rMECF1ANICAL PERMIT s S FEE' 1 _ 'FEE,SUMMARVJ,jt1_wy`!yy'P
LL I•- mit is issued.I Shall not employ any Person in any manner so as 10 e4 b✓i p, v ,rs ♦ 'p i
OW become subject to the Workers Compenslslion Laws of California. i.s 'A. ».,s,) Isco°KaLC. - `z1:'i.'.�'r
Date-Applicant BUILDING
aALTER OR ADD TO MECH. 4,00
} to NOTICE TO APPLICANT: If,after making this Workers'
Compensation
sa Ex-
f" 2 emotion,you should become
e, youto the Workers Ccomply with APPLIANCE 4.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE /
U such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10p00QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Ste. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATI NG UNIT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city and county PLUMBING
Ordinances and Slate laws relating to comply
with l city and co and BOILER-COMM H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes, BOILER-COMP IDV1r tO0,0008TU15EE 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 wa acerae'a/ya�sst Zald Ci onsequence of the PERMIT ISSUANCE 3.00
granting of lhi MECH.CONT. LIC.NO, MECH. [.= ti'
OF
TOTAL
f'-/Z TOTAL ° ' a /'A
Suinamre or APpI¢a n,,C,,nt ..Nr Date
OFFICE COPY