3025 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTI FI ION PERMIT UM
BUILDING APPLICATION & AmIT
AD025
DRESS
Qn 4 F, BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O uk EFl s - PLAN CHECK VALIDATION
NAME j � '"l ZCj '8l I I DTV. ELECTRIC PERMIT FEE
int PHONE
CONTRACTORSNAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
ADDRESS
APPLIANCES-RESIDENTIAL 4.00
CONTRAS -
PHONE PANELS - 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.80 PLAN CHECK FEE P.C.NO.
ENGINEER -
- - uc.No. " SIGNS TRANS. 3.00 GY
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTSMOTORS SEE FEE SCH.
ADDDDRESSESS
SERVICE CHANGE 10.00
00 LICENSED CONTRACTORS DECLARATION
st UI hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
InA a y BLDG. ELECT. PLG. MECH.
0 z Professions Code,and my license is in full force and effect. ❑ ❑ El
o H - License Class Li,Number
Z H o Dale - Contractor
a y f � BUILDING PERMIT
E ¢ a OWNER-BUILDER DECLARATION
o a v INFORMATION
A.
; LL w 1 herehy ufrum that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u O j
Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6,00 vALuVALUATION�E SfFT'
m� Code:Any city or county which requires a permit to emstUct,al ler, /D DI_/
QQ demolish, lELECCONTELICNO
¢0 Improve, emos ,Of repair any structure,prior to Its Issuance,also . . . . ELEC.
ta D n requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuanten the provisions of the Contractor's License //f.UM11- _
rzi
L.-(Chapter
andr9fcosion,Cde)ng with Section is 00)exempt thereion from
:aid the ,�l4YJ�'TJ
a Business and Professions Code)or that he is exempt ectiono0 and DTV. PLUMBING PERMIT FEE
rc r O the basis for the alleged exemption.Any applicant
of Section malty STORIES TYPE CONSTR.
;I any applicant fora andneddollar,subjects the Bpplicam toacivil penalty ALTER-DRAIN Be VENT-WATER
of n [more than five hundred dollars(55001.):
W I,as owner of the property,or my employees with wages us BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
tfieB Sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 .9
Code.The Contractor's License Law does not apply to all owner of
property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-ments are not intended or offered for sale,11,however the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 O[/
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.( 1.00 BUILDING USE
builder will have the hunall of proving that hedid not build or int RES IND CON PB Other
prove for purpose of sole.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to eonstE¢I the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B, 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Con Dudnr s License Law docs not apply
to killOwner of property who Builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractions)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00
the Contractor's License Law. TRACT N0. PARCEL N0.
❑ lamexemptmtder Sec._�Q ,B.&P.C.for this WATER HEATER W/VENT 4.00 ^
1C
in
Duro \ 'a - -Mw -,--dr- WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSA1 1ON DECLARATION WATER TREATING EQUIP. 4.00 --
I hereby n1flrnl Wot I have o cco hicute o1'cnnsent In self-imam, - _ ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.), L
Policy No. /Y7 Company 1
O Cl Certified copy is hereby furnished. FIRE sPRINK ENERGY T 24
Z ❑ .Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
p Applicant Y ❑ N V ❑ N
I- res PERMIT ISSUANCE 6.00
LU CERTIFICATE EXEMPTION FLOOD ZONE
W � COMI'IiNSA'I'IONlNSURANCE PLG.CONTE. � LIF N0. PLG.
d 0 (This section need not be completed i1' the permit is for are TOTAL Y❑ '^-amp
D Z hundred dollars CS 100)or less)
U O 1 certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE . FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any n o ncl'So us to
O W become subject to the Workers Compensation Laws 01'Culifontiu.
Date Applicant .�
a ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE:TO APPLICANT: If,alter making this Certificate of lix-
Fz emplion,you should become subjec(to the N'orkers'Compensalion APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith `amply wish - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.FM.) 5.00 SEISMIC FEE
I hereby affirm that entre is o construction lending a9e11CY to EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
3097,Civ.CJ. H EATING UN IT ITO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that I have read this application and stud`that the above VENTILATION FAN (SINGLE) 3.00
information a correct. 1 note to comply with all ns; and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city Io enter upon the BOILER-COMP(Over tO0,0o0 BTU)SEE FEE SCH. MECHANICAL
ahove-mentioned properly for inspection purposhe
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgingats, Costs and expenses which PERMIT ISSUANCE
may ai ny way acenm nares usill City in consequence of the
gr' ti of this perm _ MECH.CONT. LIC.N0. MECH. '
J _ �_no TOTAL TOTAL 7O l
Signaf of Applicant/Cmtractor 3 iDaro
OFFICE COPY