5337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5337
--- ADOREss .
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Y
OwNEI 5 - •�c• - PLAN CHECK VALIDATION
MN E
t DTV'. ELECTRIC PERMIT FEE
. PRON[
CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00
I.W.No. LIGHTING FIXTURES 5.00/1.00
IONTRACTORs
AGOrlliss PPLIANCES-RESIDENTIAL '4.00
zk2' PNONPANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6:00 PLAN CHECK FEE P.C.NO.
OR S //
ENGINEER
.No. SIGNS TRANS. 3.00
ARCH Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. �,•„�
SERVICE CHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION (,J
a u U I herehy affirm that 1 am licensed under provisions of Chapter 9 _ Q ISSUANCE DATE
yw (commenem•with Section 7000)of Division 3 of the Business and
Q vAi L BLDG. ELECT. PLG. MECH.
r N z Pro 1'cssinns C license is in full GnayI I fl'•m
z o w- ,icunse Class r..Number-„ c . - -' ® ❑• ❑ ❑
0 N -D n COnlNetnr
BUILDING PERMIT
¢ ¢ Q OWNER-BUILDER DECLARATION -
¢ w u NFORMATION
X ;u N I hereby affirm that I am exempt from the Contractor's L cense MISC.- REFER TO ORD ATION SIFT.
HU Law for the following reason. 7031.5,Busio.inad Professions PERMIT ISSUANCE 6.00
Code:Any city or County which requires a permit to construct,alter, ^I�
Q Q¢ Improve,demolish,or repair any structure,prior to its issuantt,aI50 ELEC.CONTR. UC.NO. ELEC. „r
a w m, requires the applicant for such permit to file a signed statement that TOTAL IT TO
he is licensed pursuant to the provisions of the Contractors License
Law(Chapter 9(commencing with Section 7000)of Division 3 of the p p� /�S
4 o Business end Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEpI
¢ $ the basis for the alleged exemption.Any violation ofSeCtion 7031.5 TYPE CONSTR.
by any applicant fora permit subjects the applicant toacivilpenalty ALTER-DRAIN$VENT-WATER (EA.) 4.00 CCY-I sill&edcr
of not more than five hundred dollars($500).):
0 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 dos not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnot intended oroffered for sale.If,hOWCveT,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builder will have the burden of printing . . ,
ing that he did not build or am- RES IND CON PB Omar
prove for purpose of sale J. INDUSTRIAL WASTE INTER. 20.00
0 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B.
5.00 ASSESSORS PARCEL NO.
and Professions Code:The Conlri elor s License Law does not apply
to an owner of property who builds ori proves therem.mad who LAWN SPR IN K LERS-OV ER 5(EA.) 1.00
cons .moncu 's License
ets Lwitha co m o licensed pursuant to SEWER-SANITARY•STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Co t,f..'s License Law.
0 1 am exempt under Sec. ,BAKC.for this WATER HEATER W/VENT 4.00
reaum
Owncr Dal° .�- WATER SYSTEM 4.00 ACC:OATE ACC.FILE NO.
WORK F.RS'COMPENSATION'DECLARATION J WATER TREATING EQUIP. 4.00
I hereby affirm that l have a certificate of consent to self-b sure, ZONING ENG.SITE NO. '
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).•
Policy No. Company -
O 0' Cerlifiedropy' her yfurnished. FIRE SPRINK ENERGY T-24Z 2 Certified c .led ao IT the •i ins ction division. MISC.- REFER TO ORD.
O ?P Iicanl Y❑ N❑ Y ❑ N❑
fLy '(,Y. I'HGM WORKERS• PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL 0 (Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars IS 100)or less.)
0,2 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE 'FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation L aws of California.
� a Dom Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 4:(,iJ•a
} m NOTICE'10 APPLICANT: If,after making this Certificate of Ex.
F 2 enlption,you should become subject to the Warken.'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of Ilia Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10AWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000.FM.) 5.00 SEISMIC FEE S D
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(Sec. MICROFILM
3097,CiYCA 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
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER•COMPI3 H.P.or 100,000 B.T.U.) 4.00
herchy authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
henvc-menlioncd property forinsp ofth i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino m,agait liabilities,judgments, costs and expenses which CONST.TAX
may i , y y uc see allot said City in consequence of the PERMIT ISSUANCE 3.00
. \ gn m Per MECH.CONT. LIC.NO. MECH.
X TOTAL TOTAL
gnalure pplie n[ nor •tor Date
OFFICE COPY