3412 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I UI LDING PROJECT I DENTIFIC PERM ry R
SU,�R EN APPLICATION & PE 3412 A 1 2
/`. I1 E" W,OLFF_ IZJA17 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL J�F I
OWNER'S -7 (' PLAN CHECK VALIDATION
`y NAME , z-J DTV. ELECTRIC PERMIT FEE
4Gu�lF T1 ► ACIIIiIW PH°NE 811 I PAIQ
CONTRACTORS
NAME pc`OUTLETS-SWITCHES-RECEP 5.00/1.00 3
UC.NG. LIGHTING FIXTURES 5.00/1.00 CD 'APR 13 1983
roNrRacroRs - PPLIANCES-RESIDENTIAL 4.00
A O DRESS
w+orvE PANELS - 5.00 •DATE felts
l
ARCHITECT SIGNS 6.00 PLANCHECKFEE 17N-,
OR
ENGINEER' I 1L `TEPOc.1r F ii4
I`kl x.J L Loy Dlc.rvo.1" ��1���""" SIGNS TRANS. 3.00
.ARC ass ENG' q SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
oUl7 1n1 LF 217 P ISJI EMP:METER OR POLE INS. 15.00
APPLICANT'S - MOTORS E F,EE�'lj
A RE55
W() r- 2t� SERVICE CHANGE 10.00 S �/
w o o LICENSED CONTRACTORS DECLARATION l Y Cupertino pqr
¢ is u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z, i fcommencing with Section 7000)of Division 3 of the Business and RII,,�pG. ELLLL�EEECT. PLG. MECH.
H D i Professions Code,and my license is in full force and effect. � � iy�I
z o r3 License Class Ltc,Number
9 D Date Contractor
NL• j
It ¢ w ¢ OWNIi R-B UILUER DECLARATION _ N
E 0aa MISC.- REFER TO ORD
se g;LL I- I hereby affirm that I am exempt from lire Contractors License
F u o¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 4e` L A IDN $/F.T.
Code:Any city orcounly which requires a permit to construct,
ELEC.CONTE. LIC.NO.
a ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to The provisions of the Contractor's License Iy
H z a
Law(Ch apter 9(com me rebut wit h Section 7000)o f Divisio n 3 of One /,V7edR1UQ )(7CHO,JeL
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
in t- in the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
is. by any applicant for u permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five lmndred dollars(55001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
their sale 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:T'he 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 SQ FT.FLOOR AREA TOTAL ACREAGE
himself re of intended
his own employees,provided that such imPmve-
mentsurenotintended or employeesale.lf,ed that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OV OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or no-
prove for purpose of Sale.). INDUSTRIALWASTE INTER. 20.00 RES IND CON Pe Dune.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5IEA.) 1.00 -
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. for this WATER HEATER W/VENT - 4.00
\/ reason
1� Da[e Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to se 1-ins uc.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.L-
Policy No, Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD,
p Applicant 1 Y [J NO Y ❑ NO
p: w PERMIT ISSUANCE - '6.00
� - CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U C:
.L.UC:
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO, PLO.
n' 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ V ❑ N❑
Z hundred dollars(5100)or less.) p/������
0 O. I certify that in the performance of the work for which this per- QTY. MECHANICA6Tlfa6%- FEE FEE SUMMARY
U, I- mit is issued,I shall not employ any person in any manner so as to
0 w become subject to the Workers'Compensation Laws of Californiu, y
Date Applicunt BUILDING /�T+
} N NOTICE 'f0 APPLICANT: If,after making this Certificate of lix- - ALTER OR ADD C� 4.00 V.
? emption,you should become subject to the Workers'Compensxlirn APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C..1 such provisions or this permit shall he deemed revoked. AIR HANDLING UNI 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER IO C.F. .15.00 SEISMIC FEE ,
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(Sec. MICROFILM
3097,Cie CA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
ss HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and state thin the above VENTILATION FAN (SINGLE) 3.00
information a correct I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 Lti PLUMBING -information
aril state laws relating to building construction,and
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEESCH. MECHANICAL D'-C
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C ertino against liabilities,judgments,lasts aril expenses which PERMIT ISSUANCE 3.00 CONST.TAX
to in any wX ra against said City co in nd a pence of the
It
ting ' thi . MECHCONT. LIQ N0. MECH.TOTAL ` TOTAL3U, 7;6
Signature olAt/Contractor Dnte
OFFICE COPY