3411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
r BUI LOI NO PROJECT I DENTI FIC PERMI UMBER
D
AILDD EIN SSpAPPLICATION & PE ,� A
1pV IUPLF[� 2Q BUILDING — ELECTRICAL—PLUMBING—MECHANICAL `j L�
11
OWNER'S Q PLAN CHECK VALIDATION
NA E cwLcrr Phtil PHONE 7 QTY. ELECTRIC PERMIT FEE
9 WR 1 PAID
CONTRACTORS - 1
NAME UTLETS-SWITCHES-RECEP 5.OU/1.00 y
/t1�ThL.CO C3L06-•T ,J LIC.NO. LIGHTING FIXTURES 5.00/1.00 MAY, b.tiiBJ -
CONTRACTOR (/( APPLIANCES-RESIDENTIAL 4.00 (1
oa 4Al}/C.Q C4 PHONE PANELS 5.00 yr N
ARCHITECT SIGNS 6.00 PLAN ECK FE .C.NO,
J
ENGINEER
OLIc.No. SIGNS TRANS. 3.00
ADDRESS ENG. PEflMIT VALIDATION
aooREss SPECI R 5.00
MET08
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH. ) d6ADREss ^
GAC/c SERVICE CHANGE '10.00 {� / _��
102 LICENSED CONTRACTORS DECLARATION v [Q
a is v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I-z W (comm�encing with Seclioo 7000)of Division 3 of the Bosine,o and
y ¢ e. SLUG. ELECT. PLG. MECH.
H o z Professions Code,and my license is in full force and effect ❑ ❑ ❑
z 0 w - License Class Lie.Number
o m t o Date Contractor
¢ Y E J BUILDING PERMIT
IF a, rc a OWNER-BUILDER DECLARATION
W U INFORMATION
w ; u H I hereby affirm that I am exempt front the Contractor's License MISC.— .REFER TO ORD
u o j Law for the following reason.(Sec 7031.5.Business and Professions VALUATION $/FT.
_ g PERMIT ISSUANCE 6.00
PIS Code: e,dear y or county whiny structure,cra
prior
1 o construct,alter,also
S It ¢Q improve,demolish,or repair any s'truclure,prior tO its issuance,also ELEC.CONTR. LIC.NO. ELEC. O,�
n w0 Ie requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
H he is licensed pursuant to the provisions of the Contractor's License
r z � Law(Chapter 9(commencing with Section 7000)of Division 3 of the
z o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE '
¢ F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
iR „ by 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): '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP 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 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 TOTAL ACREAGE
himself re through his own employees,provided that such improve-
mmself enot intended own
dfor sale.provided
that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA1 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB Omer
prove for purpose of sale,), I N D USTR I A L W ASTE INTER.---��0.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ Ellicensed contractors to construct (lie project(Sec. 7044,Business LAWN SPR INKL Rg- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO,
and Professions Code:q'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPR LERS-OVER 5(EA.) 1.00
contracts for such projects with u contruclods)licensed pursuant to
SE
the Contractor's License Law. INE ANITARV-STORM EA,200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 exc tI' i.&P.C,for this WATER HEATER W/VENT 4.00
`/ reason (
_1` Dote - wtl r WATER SYSTEM rs n3
0 r ACC.DATE ACC.FILE NO,
WORKERS'CWRNSA'I'[ON DECLARATION WATER TREATING EQUIP. '00
I hereby affirm that I have a certificate of consent to self-an
U a certificate of,Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C).
Policy No. Company
O ❑ Certified copy is hereby furnished, ON Of FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO R
0 Applicant - Y ❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 6.00
JU — CERNFICATE E I ATION INS FROM WORKERS FLOOD ZONE a.t.u.c.
W � COMI'F.NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 Q (This section,need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
3 Z hundred do Ban,IS 100)or less)
U O I 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 manner so as to
U hecome subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
a ALTER OR ADD TO MECH. 4.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you nwst t'orthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.NL) 3.00
CONSTRUC'nON LENDING AGENCY AIR HANDLING UNIT(OVER 10OWCEM.) 5.00 SEISMIC FEE /
I hereby affirm that there is a constoctir"leading agency fur EXHAUST•HOOD (WITH DUCT) 2.00
tile performance of the work for which this Permit is issued(Sec. MICROFILM
3097,Civ C.). �UNI�
Lender's Address HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 13.T.U.)7.50 ELECTRIC
I certify that 1 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
ordinances and state laws relating to building constnmfion, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMPAOvnr 100,000 BTU)SEE FEE SCH. MECHANICAL
move-mentioned property for inspection purposmenfinned 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 Ci y In consequence of the
g ant' g this P rmi1 a MECH.CONT, LIC.NO. MECH. /
/5���t� TOTAL TOTAL 99 JL
Signature of Applican l/Contractor Date
OFFICE COPY