14098 APPLICANT TO FILL IN INF TION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUI LDI NG PROJE TIDENTI FI PERMIT NUMBER
4Ar;OEN d[.1-dr d APPLICATION & PER 0
ILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNERS - - PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
�� PHONE
NAMERacTORs UTLETS-SWITCHES-PIECED 10.00/1.0 -
Q� uc.NC, ; 3?/ ILIGHTING FIXTURES 10.00/1.00 _
CONT acTOR's
ADDRESS - PPLIANCES-RESIDENTIAL 4.00
$ORE %'" ,/�
a sx yQ` 1Qy PHONE 17btu 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
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS., (a,r^- 20:00
AMOTORS ' 'I SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE '20.00
wISo LICENSED CONTRACTORS DECLARATION /
a v u I hereby affirm that I-am licensed under provisions of Chapter 9 ISSUANCE DATE
Z, to com Section(commencing g with 1 n 7000) i Division 3 of the Business and
�n¢ u BLDG. ELECT. PLG. MECH.
i Professions Code,a d my license is in full for , ft ' Awn ❑ D
Z O=- Ir
Licen I�s i Lic.Numbs
o y H w Date Contractor /f,r 1A(cl,u �1H.t J-Q
a x l40 BUILDING PERMIT
¢ ¢a OWNER-BUILDER DECLARATION '� '�L
o a v INFORMATION
X 3 LL y 1 hereby affirm that 1 am exempt from the Contractor's License FEB TO ORD
HLLOJ Law for following reason. 7031.5,BusinessandProfessions PERMIT ISSUANCE 10.00 VALUATION $/FT.
¢ rcw Code:Any city or county which requires a permit to construct,alter,
¢IS improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i c¢ requires the applicant for such permit to file a signed statement that TOTAL/S� PERMIT TO
X m he is licensed pursuant to the provisions of the Contractor's License �r
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc EGG
a Business and Professions Code)or that he is exempt therefrom and DTY. PLUMBING PERMIT FEE
¢r $ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
i ;,. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 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 sole compensation,will do the work,and the structure is Got
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• properly who Inuids 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-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4'OUTLETS 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 im- - RES IND CON PB Other
prove for purpose ofsaleJ. INDUSTRIAL WAS TE INTER. 30.00 - ❑ El [D El❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does 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 with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
Cl I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
ora certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.
Policy No. Company Gb7J
0 ❑ Certified Copy is hereby furnished. FIRESPRINK ENERGY T 24
Z Z 1WCertif til d w the city inspection division.
O Applies 7�� -- - MISC.- REFER TO ORD. Y ❑' N❑ Y ❑ N❑
�' va PERMIT ISSUANCE 10.00
LU - CERTIFICATE EXEMPTION FROM WORKERS' FLOODZONE A.L.u.c.
W � COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
I Z( This Section need not be completed if the permit is for one TOTAL Y F] N❑ Y E] N❑
hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this per- CITY, MECHANICAL PERMIT FEE FEE SUMMARY
LL 5mit is issued,I shall not employ any person in any manner,so as to
U become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. - 5.00 BUILDING
)- m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
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 be deemed revoked. AIR HANDLING UNIT(TO 10)OODC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G U N IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.Dr 100,000B.T.U.) 6.00
x hereby authorize representatives of this city to enter upon the BOILER-COMP IDVar 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- I ,REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in ny way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grant' of this L I MECH.CONT. LIG NO. MECH,
TOTAL TOTAL
F^nature of Applicant/Contractor Date
OFFICE COPY
I.