2803 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
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BUILDING PROJECT IDENTIFICATIONBUILD
lSc APPLICATION & PERMIT
ADDRESS CUO _L
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL 2803
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PLAN CHECK VALIDATION
OTY. ELECTRICPERMIT', :FEE�� PHON19I >_/ . 1. aG
CONTRACTORS LCNo3 / OUTLETS-SWITCHES-RECEP 0O0OI17.0000
NAMEI . LIGHTING FIXTURES
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS a N' //J)
ySl !3. O 1? CTPHONE I PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS
ENGINEER 6.00 PLANCHECK FEE P.C.NO.
DR
s set.No. SIGNS TRANS. 3.00
ADDRESS EN SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION
< v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a (commencing with Section 7000)of Division 3.f the Business and BLDG. ELECT. PLG. MECH,
r o i Professions Cos a se is in full force and effect. ❑ ❑ ❑
o Z_ay Licens IasssLic.Numb
er
Zwt j Date Contractor7KJi
n ¢ a OWNER-BUILDER DECLARATION ' I- ING PTI ?v��
A o a M MISC.- REFER TO ORD � *� ORMATION.'''v�,6T:
X 3 N 1 hereby affirm that 1 am exempt from the Contractor's License J
Fy04 Law for the following reason.(Sec.703 1.5,Busineuand Professions PERMIT ISSUANCE 6.00
s Code:Any city orcounty which requires a permit to construct,alter, 9f`
C 5 < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
0
requires the ikon[for u o o e a signed statement that TOTAL
q pp r s ch permit t J 8 I B s d0 Q
E
he is licensed pursuant en the provisions of the )of Division
License _ -
r Law(Chapterand
Professions
Code)or Section is exempt therefrom the /'' %-;:" �, ;;:tst�=a!,; , ' 7, x .'. -v .�,.'. ijr'vEE �40 �pomp/
<
Bus mess and Professions Codel or that he is exempt therefrom and QTY. f w 7 ` PLUMBING PERMIT s y t Ir ! '" �Y---
o the basis for the alleged exemption.Any violation of Section 703 LS ." :+ _ :. r' X.' v?. ...S�,h S.- -., s - SI 6..y'y r STO TYPE CONSTR.
aby any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4,00
of not more than five hundred dollars($5001.):
Cl I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.CROUP 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 Contractors 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 SO.FT.PLGORAREA -TOTALACREAGE
. himself through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
maims arere not intended or offered for sale.If,however,the building
or improvement is sold within one year oft he did ion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of ale.). INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,he rojectiv Se contracting with ❑ ❑ ❑ ❑ ❑
licensed colons od to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The hbuildsContractor's License Law does not apply
to an owner of Property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts Contractor's
h projects with a conlrocmdsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Dale Ownef WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofcunsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workeri Com enation I surance,or a art led
copy thereaflSec.3800,Lab.C.). is
'x Policy No. Company f�
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifie o y is a ith Cil euion division.
p Applicam - MISC.• REFER TO ORD. tON❑ YN~ PERMIT ISSUANCE 6.00 E A.L.u.c.CERTIFICATE OF EXEMPTION FROM WO 'ERS'W COMPENSATION INSURANCE PLG.CONTR LIC NO. PLG ❑ Y❑ N❑
d O (This section need not be completed if the permit is for one TOTAL
Z hundred dollars(S 100)Of Iea.)
U O 1 certify that in the performance of the work for which this per. DTV. }.,MECHANICAL.PERMIT ( F`EE / I LHb.';FEE SUMMARY R.9fu11`i
ly F- mit is issued,I shall not employ any person in any manner so as to _ �.P I s•2 t;T" x 1
O become subject to the Workers'Compensation Laws of Calimmia. fV
0 i Date Applicant ALTER OR ADD TO MECH. ,•4.00 BUILDING :�-
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex.
L.. Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith Comply withFEE 33
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op000.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 5.00 SEISMIC FEE -70
I hereby affirm that then is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance ulthe work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Addss HEATI NG UN IT(OV ER 100,000 B,T.U.)7.50 ELECTRIC
re
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
ordinances n correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building l city and co and BOILER•COMP(3 H.P.of 100,000 B.T.U.) 4.00
hereby authorize representatives of this City to enter upon the BOILER-COMP (Over 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.• REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which CONST.TAX
may in any way accrue a ''ns[laid City in consequence of the PERMIT ISSUANCE 3.00
gran) ofthisper)iit. MECH.CONT. LIC.NO. MECH. .-J :y +',�;i,' n
TOTAL S
:TOTAL 4u
Ignamreof App ant ontractor Date •.°:
OFFICE COPY