3157 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON P7715
BUILDING APPLICATION & PERMIT 7
ADDRESS
D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O N RS :'r". - - -' - - Y*r PLAN CHECK VALIDATION
;. /
"AME OTY: ELECTRIC PERMIT a `FEE
ONE
c NTRAcaoRs UTLETS-SWITCHES-RECEP 5.00/1,00 /
NA E
LIC.NO. Q q LIGHTING FIXTURES 5.0011.00
ADDDRESSRESS o Ds 9 PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE as/T- •O I(j PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR eENGINEER4- n Q�d�J
F a� uc.Nor SIGNS TRANS. 3.00 "/
ARCH
.OR ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
!J` ADDRESS ,
N BO ZIP AHO li TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
W o o LICENSED CONTRACTORS DECLARATION 'D
a v u 1 hereby affirm that I am licensed under provisions of Chapter 9 ASJUANCE DATE
ve a (commencing with Section 70001 of Division 3 of the Business and B G OT. PLG. MECH.
0'^ Professions Code,and my license is in full force apd�f eft ❑ ❑ ❑
o 0=0 License Class _ Lic.Number YY
asH w Date Conrmctor
Cil hl DING PERMIT-tn3.:'"
a Q a¢ OWNER-BUILDER DECLARATION , "L}
A 0-.0 MISC.- REFER TO ORD ?:INFORMATION -
m gvi I hereby affirm that I am exempt from the Contractors License VALUATION
Ito ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
I= Nve Code:Anycity orcounty which requires a permit m construct,alter,
¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.LONTR, LIC.NO. ELEC.
F. LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
F.
he is licensed pursuant
umt to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section f ision 3 ofthe
a
¢ Business and Professions Code)or that he isexempt therefrom and OTY: 'PLUMBING PERMIT,: FEE'
2 _$ the basis for the alleged exemption.Any violation of Section 7031.5 ';Vn' •+ '.4;-Yr'P°-a" S 'i'- • 1'..'r I-I".tri,. - r ' STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant toacivil penally ALTER-DRAIN& VENT-WATER IEA.) 4.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITE
(hear 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 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.FLOOR ARE TOTAL ACREAGE
himselfthrough own improve- °r
mems arere not intended or offered for sale.If. GAS -1 INC.4OUTLETS 4,00 however,the building n
or improvement is sold within one year of completion,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
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES,' IND CON PB .oth4s
❑ I,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. 5.00 ASSESSORS PARCEL NO.
and Prafessiam Cade:The Contractors License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00 f '
contracts for such projects with a contractors)licensed pursuant to
rhe Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec._,B.&P.C.for this WATER HEATER W/VENT 4.00
Rdsan
Date Owner 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 ofconsent to self-insure. ZONING ENG.SITE NO.
or a Certificate of Workers Compensation Insurance,or a certified
copy(hereof(Sec.3800,Lab ')A
Policy No. Company !1(aRAn/,oBr¢'L
❑ Certified copy is hereby furnisheJ. w�' . FIRE SPR( K ENERGY T-34
Z Z ❑ Certiiw ca y. �S wl'^yh t; ty in pegtt division
A can l tI6 . MISC.- REFER TO ORD.
Y [:] N Y ❑
IlL N
~ H -
LU CERTIFICATEEXEMPTION FROM WORKERSPERMIT ISSUANCE 6.00 FLOODZONE
'
W � COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG,
(. O (This section need not be completed if the permit is for one TOTAL Y❑
� Z hundred dollars l$)00)or leu.) q , " ' e'•,?1 - :L7�; v 1L.1 Q 1 certifythat in the performance of the work for which(his er. 4 s,FEE SUMMARY.''.y:
p p GTV'. n- - ,.'MECHANICAL PERMIT FEE •5 a z,,, _ _ -
UL mil is issued,1 shall not employ any person in any manner so as to
U become subject to the workers Compensa(ion Laws of California r d d
O Ou Due A lican( BUILDING _ V,53
Q. pp ALTER OR ADD TO MECH. 4.00
} us NOTICE TO APPLICANT: IL after making this Certificate of Ex-
1... z emption,you should become subject to the Worker Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 9�
I 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 ISec. MICROFILM
3097,Civ.C.l, HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN(SINGLE) 3.00
information n correct I agree tcomply with all city and county PLUMBING
ordinancesordinancesandirnnd stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANI
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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
grant go Is pe nit MECH,CONT. LIC.NO. MECH.
2-/L- $J
TOTAL -,(:T0TAL'»:, '.5/4A
f SilmSurc of Applicant/Conlmctor Date :1.•..Ij•-.I'•
OFFICE COPY