3229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• PER UMBER
+ BUILDINGPROJECT IDENTIFICI T APPLICATION & PEF* - 3229
ADDRESS M
TOORF55 I�
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
0 rvERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ON
IW
c NTRACTORs
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
.41C NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
A OGRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NNOO,
OR a�V
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00 �{/D 4T
ARPucANrs MOTORS SEE FEE SCH. O✓ O�
ADDRESS
SERVICE CHANGE 10.00 1140, r
0 o O LICENSED CONT RACTORS DECLARATION
¢ o U I hereby affirm that I am licensed under provisions of Chapter') ISSUANCE DATE
v, G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ECT. PLG. MECH.
r N z Professions Code,and my license is in full force and effect. /11i+ ❑ ❑
z 0 m - License Class Lic.Number
2 z w Date Contractor
Q s QpB IL 1 P RMIT
¢ w ¢ OWNIi R-BUILDI°R DLCLARA'f10N 1n` t j ION
" MISC.- REFER TO ORD
w °g LL H I hereby uffnm that 1 um exempt front the Contractors Licvuc VALUATION S)FT.
FUOa Law forthe following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 �.s(y�
Code:Any city promptlywhichrequiresapermittoconstruct,ulteq CW'P-'/j M1�1tI�IQ
2 ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
0 u quires the applicant for such permit to file a signed statement thRMI
at TOTAL
a w m requires
is licensed pursuant to the provisions of the Contractor's License E �n
FZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /1
f 4 0 Business and Professions Code)or that he is exempt theretront and QTY. PLUMBING PERMIT FEE C
¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES �TY�•PE/CON/(S�TR.
n ; w by any applicant for a permit subjects the applicant to1.a civil penalty ALTER-DRAIN Br VENT-WATER (EA.) 4.00 / IJ N�//IF
of riot more than five hundred dollars(55001.1:
❑ 1,as owner of the property,or my cmpluyces with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 �xs
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 AREA TOTALACREAGE
himself or through his own employees.or le,If,cd that such improve .�.�
mmsello through
of or offered ce......vidooweventhebo0ding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement Is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA ) 100 uaOING USE
builder will have the burden of p - . . .
roving that he did riot build or im- RES IND COIR PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El ��
❑ I,as owner of the property.ran exclusively contracting with
El El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Licepw Law docs 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 cuntractons)licensed Pursuant m V
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ion exec ptundcr ec. I.E.&I' o"this WATER HEATER W/VENT 4.00
reason
Dplc - Ow'^er WATER SYSTEM 4.00 ACO.OATE ACC.FILE NO.
�� ✓ W RI SIPENSA'I'ION DFCLARAFION WATER TREATING EQUIP. 4.00
1 hereby affirmthatI have a certificate of consent to ul&insstre.
or:h ccrtifraw of Workers'Compensation Insurance,or it certiflcd ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). �..�
Policy No, Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T.24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.O Applicant N❑ Y 0 N)4
� N CIiRTIPICA'I'IS OP IiXEM11 P'I'ION PROM WORKERS'
PERMIT ISSUANCE 6.00 FLOODZONE � ^
Ill > COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O ('This section need nal be completed if the pernit isJor one TOTAL V❑ Ny$1 "T"
Z) Z hundred dollars IS 100)or
U O 1 certify that in the porl'or lance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any pumper so as to
U bccoun subject to the Workers Cm,punwGon Laws of California.
O w Datc Applicant BUILDING O J
a ALTER OR ADD TO MECH. 4.00
} rA NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F_ ? emption,you should become suboud w the Workers'Compensation APPLIANCE 4.00 PLAN CHECK T 1 j
provisions of the Labor Code, you must forthwith comply wilh FEE oK
V sum provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10fWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE e
I hereby affirm tlta( then is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the penoripance of the work for which this permit is issued IS". MICROFILM
3097,Civ.CJ. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Nano HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender i Address
I ce,t,ly that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
orAlnonees 'and state laws relwing ds building a hntruction, and BOILER
-COMP(3 H.P.or 100,0008.T.U.) 4.00
"IbLreby authorim representatives of this city to enter upon the BOILER-COMP IOVar 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,judgmanB, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue aguiry�t unit City in con eq a ee of the
gr olio s" rs /
MECH.CONT. LIC.N0. MECH.
JI �(C� OTAL TOTAL /So/ 7/
ignaturu of Applicant/Contractor 1
OFFICE COPY