3944 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
aDILDING APPLICATION & PERMIT 3944
AODR E55
FfT��-� D,e BUILDING —ELECTRICAL—PLUMBING—MECHANICA
OWNER'S LAN CHECK VALIDATION
"AME
yf /hI//�_/ PHONE OTY. ELECTRIC PERMIT FEE "
/Pos
NAMECONTRACTOR OUTLETS+SWITCHES-RECEP 5.00/1.00
NAME �
O_y LIGHTING FIXTURES 5.00/1.00
CONTRACTOR I APPLIANCES-RESIDENTIAL 4.00
ADDRESS
/,o 011;F61 /�/�i'P/SfL NbHONEPANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00
PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADD ESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANTS
MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 YA1
oo LICENSED CONTRACTORS DECLARATION ��UI hereby affirm shot I um licensed under provisions of Chapter 9 E DATE
NG a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H O i Professions Code,and my license is in full force'nd Ree ❑ ❑
i.n.`4 License Class hie.Number _
m H Uale C'07U'ontractor
¢ y s BUILDING PERMIT
¢ ¢ w a OWNER.BUILDER DECLARATION
E: o A D MISC.— REFER TO ORD INFORMATION
LL w 1 hereby affirm that I am exempt from the Contractor's License q u g/FT.
Hooef Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit t0 construd,alteq //00
¢ ¢ ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. CI
—o¢ requires the applicant for such permit to Glc a signed statement that TOTAL IT TO
X
$ he is licensed pursuant to the provisions of the Contractor's License ha
H z i Law(Chapter9(commencing with Section 7000)of Division 3 of the le-/�f'�/Q U CdCTiC�
a Business and Professions Code)or that he isexempt therefrom and DTV. PLUMBING PERMIT FEE
¢ I-- D the basis for the alleged exemption.Any violation of Seclion703L5 STORIES TYPE CONSTR.
n by any applicant for a permit subjects tiro applicant toil civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500)J:
❑ 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 sl ructure 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 docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
L� himself or through his own employees,provided that such improve-
ments
mprovemeets are not intended or offered for sale.If,however,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,roving that h . . .
e did not build or int- RES IND CON PB Orae,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ I,As owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INCd3 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.)
contracts for such projects with a contractors)licensed pursuant to
the Commctor's License Law. SEWER-SANITARY-STORM EA.2014.001
TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT
reason
Dare Owner WATER SYSTEM ACC.DATE ACC,FILE NO.
WORK I:RS'COldPENS^TION DECLARATION WATER TREATING EQUIP.
1 hereby affirm that I have a certificate of consent to self-insure. _1 ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerJlfied
copy thereo�f I�S}-y--L3.8.00.Lab c.).4.✓f/j be?T,rJ/+' -
Poll cY NrizYL( Vtorany g7.ry1, �._„A',p —
O ❑ Certified copy is hereby rut FIRESPRINK ENERGYT-24
Z 2 ❑ Cetlifie y is GI '84'pe division.
C A,plicant� — MISC.- R T Y❑ N❑ Y ❑ N❑
0: CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT I'SSUKNW FLOOD ZONE A.L.U.C.
LU >- COMPENSATION INSURANCE PEG.CONTE. LIC.NO. PLC.
CL CL 0 (This section need not be completed if the Penn it is I'., one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I'shall not employ any person in any Fanner so is to
U become subject to the Workets'Compensation Laws of California.
Q i
Date—Applicant ALTER OR ADD TO MECH. 4.00 BUILDING _
} to NOTICE TO APPLICANT If,afros making this Certificate of fix
?
coalition,you should become subject to the workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=12—F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE .S'V
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the 3097 Ci
performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM -
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.0.50
Lender's Address ELECTRIC
I certify that I have read this application and state tient the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree t0 comply with all city and conduction, a d PLUMBING
ordinances and state laws relating Io ly withg lcityandnand BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the 000 BTU)SEE FEE SCM.
BOILER-COMP IDVaf 100,
- above-mentioned property for inspection purposes. MECHANICAL
(WC) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agai iabilities, Cots costs expenses which CONST.TAX
may in any ay ucc 1 gainst So it ons once of the PERMIT ISSUANCE 3.00
greatispermit MECH.CONT. LIC.NO. MECH.
-�` TOTAL TOTAL 9.fU
Signature Of AppliwnNContmd Dam -
OFFICIi COPY