3789 APPLICANT TO FILL IN INFORMATION WITHIN.RED'LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENT]FIC PERMIT NUMBER
ED 4mNG APPLICATION & PE T
ADDRESS BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 3789
wNER'S If PLAN CHECK VALIDATION
" ��i 'y IGM.XJ DTV. ELECTRIC PERMIT FEE (,,
PHONE /7O
CON RACTOR'a
Na E OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS APPLIANCES.-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00 y73
ENGINEER
" uc.NO SIGNS TRANS. 3.00
ARCH.SS ENG. PERMIaDATION
ADDRESS SPECIAL CIRCUIT 5.00
z,v EMP.METER OR;POLE INS. 15.00
CH. �
ADDRESS - MOTORS -SEE FEE SCH. j
ADDRESS -
SERVICECHANGE 10.00 II' 9q •11((x](1
w
a u00 LICENSED CONTRACTORS DECLARATION p J ISSCANCE fiATIB7�
v I herebyaffirm that I am licensed under revisions of Cha ter 9
H G a, (commencing with Section 7000)of Division 3 of the Business and BLDG. I ELECT. PLG. MECH.
H H z Professions Code,and my license is in full force and effect.-
Z,z w o License Class Lic.Number it& CU— In 11
Date Cnn tractor
¢ x E BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
u, uINFORMATION
w3: ` N I hereby affirm that I am exempt from the Contractor's Licensc IMISIC.- REFER TO ORD
F u o a.i Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 V�sA.LUATION�r $/FT.
,A0 Code:Any city crcounty which requires a permit to construct,alter.
¢ ¢¢2O improve,demolish,or repair any structure,prior to its issuance,also ELEC CONTR. LIC.NO. -
¢ requires the applicant for such permit to file aligned statement that TOTAL PERMIT TO
d w $ he is(Chapter
d pursuant to the provisions of the Contractors Licensc /
tit Law(Cha nd Procesu.n, ode)with Section 7s 00)exempt
the of om the
and
a Business and Professions Code)ort n lie i is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r � the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penahy ALTER-DRAIN&VENT-WATER (EA.) 4,00 9
of not mare than five hundred dollars(SSOO).): V�
❑ 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
hint are not
own employees, le.If,however,
such improve- GAS-EA.SYSTEM-1 INC. OUTLETS 4.00
men is are not intended or offered for sale.If,ed that s the building
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. 2000 RES IND Dow PB Other
El 1,as owner of the property,am exclusively contmming with ❑ Z�_ ❑ ❑ ❑
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 License Law does not apply
to as owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 -��� /Y
contracts for such projects with a mntractm(sl licensed pursuant to (((��� ' r
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iaan •temt 1wer Sec.---�--�- B.&PC.forthis WATER HEATER W/VENT 4.00
reason i �i w+A
J` Date Owne,_er'zl_ WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WO KERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent In sell'-insure.
or 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 Immished.
z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-29
O Applicant MISC.- REFER TO ORD. Y�6 -El Y N❑
~ w PERMIT ISSUANCE 6.00
LU — CERTI FIC(70 OF EXEMPTION INS PROM WORKERS' FLaoo ZONE �
W � COMPfiNSAfION INSURANCE. PLG.corvTR. LIC.No. PLG. '
(L 0 (This section need not be completed if the permit is for One TOTAL Y❑ V --B—_p
ZD Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
L) become subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 4,00 BUILDING I? TI
7$Z
>_ N NOTICE TO APPLICANT: If,after making this Certificate of IN-
I- emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
previsions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C-F.M.) 3.00 /
CONST'RUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10pWOEM.) 5.00 SEISMIC FEE \33,6
I hereby affirm that there is a constructionlending agency lot EXHAUST HOOD IWITH DUCT)' 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CiYC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify Ihut I have read this application and stale that the uhove VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all City and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.1 4.00
hereby aulhorin representatives of this city to enter upon the BOILER-COMP IOver 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,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX,
May in ny way aceysa-•q�u' st said Cit in eo q IcmCC of the
gra7rl0g f IIIiS p 11 MECH.CONT. LIC.NO. MECH. _
1 111, TOTAL TOTAL 027736
are 01 Applicant/Cnntrac or at
OFFICE COPY