3725 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13UI LDI NG PROJECT I DENTI FICATION P IT NUM ER
yN SoILOING APPLICATION & PERMIT 3-725
ADDRESS
DO L .177�- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S l -lC�V7� PLAN CHECK VALIDATION
NAME
'1 DTV. ELECTRIC PERMIT FEE _ p ( �]
C 1.•G 1\ 1 RE Z� -c �+D/ Ie /�,� {p//
CONTRACTORS NAME UTLETS•SWITCHES-RECEP 5.00/7.00 �(J (� �- /�3
rj LIC.NO. LIGHTING FIXTURES 5.00/1.00
ADOREAcrOR's PPLIANCES-RESIDENTIAL 4,00
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
- uc,NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.06 PE VALIDATION
zav frEMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS /~
A
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARA'TON 5 Rq)
a i w I hereby affirm that I am licensed under provisions of Chapter 9 19l4STaANDE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
P,
D i Professions Code,and my license is in full force and effect.
o 0 to W License Class Lic.Number f rope fi[i]o ❑ ❑
Date - Contractor
¢ y E BUILDING PERMIT
¢ ¢w ¢ OWNER-BUILDER DECLARA'T'ION INFORMATION
se ;LL N I hereby affirm that I am exempt from the Contractors License IMISC.- REFER TO ORD
H u O j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city or county which requires a permit to constnmL otter, A
rt2aoimprove,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n w- G LL requires the applicant for such permit to file a signed statement thin TOTAL PERMIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
H zawCo [er9(commencing with Section 7000fDivson3oth 'a/ OxE> /AJ7&Z.0
a Business and Professions Code)or that he is exempt therefrom and DTV- PLUMBING PERMIT FEE
rc = $ the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollars(S5001.): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 ace.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to as owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.60 50.FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees.Provided that such improve-
ments arCnot inghhis otfeyed for provided
that r.suhcbuilding GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or IMProvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or it"- . . .
- RES IND CON PB Omer
prove for purpose or sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he 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 -
contracts forsueh projects with u contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA,200ft/8.00 TRACT NO. PARCEL NO.
❑ 1"am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Date Ow"� WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATI .�u/ WATER TREATING EQUIP. 4.00
1 hereby:dfirm that I have a certificate ofconsent m selpinsure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z z ❑ Certified copy is riled with the city inspection division. RE gPRINK ENERGY T-Z4
MISC.- REFER TO ORD.
O Applicant Y ❑ . N❑ Y ❑ N❑
� N CER1'IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COAIPFNSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
0 m
(This section need not be if the pe is for one TOTAL Y❑ N❑ Y F] E]
N
ZD Z hundred dollhrs IS 100)or less.)
U O I certify that in the performance of the work for which this it, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL P: mit is issued,I shall not employ any person in any manner um as to
U become subject to the Workers'Compensation Laws of California.
O a Date APPliant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOT'IC17 TO APPLICAN"I': If,after nmking this Certificate of Ex-
� 2 .emp!i.P,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK -
,itvisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0GE
00M.) 5.00 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nddr HEATING UNIT(OVER 100,000 B,T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information ncornet.Is agree to comply with aII city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.1 4.00
hereby authorize representatives ec this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
herebaboveyn authorize
properly far vesp of this
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
Clay in any way accrue against said City In Consequence of the
gm goflhis ,
permit // p MECH.CONT. LIC.NO. MECH.
A TOTAL TOTAL 11YeO
na .�
Sigture of A ppliC' Contractor / e
OFFICE COPY