3945 APPLICANT, TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
P
BUILDING PROJECT I DENTIFICATION ERMIT NUMBER
BUILDING APPLICATION & PERMIT 3945
ADDRess Ob
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
NAME
OWNER'S
LAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
PHONE
NAII`lNFNTRACTD9S UTLETS-SWITCHES-RECEP 5.00/1.00
it ME
.No.` IL}ol Pn
LIGHTING FIXTURES 5.00/1.00
CONT ACT APPLIANCES-RESIDENTIAL 4.00
ADORE
3o OrvE 1 PANELS 5.00 DATE OF APPLICATION
ARRCHITECT I SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.rv0. SIGNS TRANS. - 3.00
ADDRess ENa SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
• A°PLICA MOTORSSEE FEE SCH.
ACOR s
11
SERVICE CHANGE 10.00
Foo LICENSED CONTRACTORS DECLARATION �-A
ri w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
< (co oniencink with Section 7000)of Division 3 of the Business and BLDG. ELECT. - PLG. MECH.
H w A Professions C Je. d y license is in full fo n c
Z,o m- Licenu ns_ _ .(d_Lic.Number
yF w Datc Contractor e
a m s - BUILDING PERMIT
¢ Be c OWNER-BUILDER DECLARATION
o a U INFORMATION
w3 LL H 1 hereby affirm that I em exempt from the Contractor's License MISC.- REFER TO ORD
FLLy J Law fertile following reason.(Sec.7031.8,Business and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code'.Any city or county which requires a permit to construct,alter,
¢ ¢¢ mp
irove,demolish,or repair any structure,prissuance,a
prior to its ilso ELEC.CONTR. LIC.NO.
Q _ ELEQ
B. w m LL requires the applicant lot such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contmi s ctoLicense
H z i Law(Chapter 9(commencing with Section 7000)of-Division 3 oflhe
< Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
sin
¢ H $ by basis for the alleged exemption.Any applicant
of Section malty STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant rna civil penalty
of not more than five hundred dollars($5001): ALTER-DRAIN&VENT-WATER (EA.) 4.00
Cl L as owner of the property,or my employees with wages as BACKFLOW PROTECTDEVICE 200
their sole compensation,will do the work,and the Structure i . .
s not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.0
Code:The Contractor's License Law does But apply to aB owner of -
propertywhobuildsorimprovesthereon,and WhO(IOCS SnC1l Wolk FIXTURES-PER TRAP 4.00 0 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his awn employees,provided llat such innprove-
mentsarenotintended or offered for sale.If,however,file building 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 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB One,
prove for purpose ofsnle.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with [:] ❑ E] ❑ ❑,
licensed contractors 10 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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contraclons)licensed pursuant to �x,�
the Contractor's License Law. UNSEWER-SANITARY-ST 200ft/8.00 TRACT NO. PARCEL NO.
16
❑ l am exempt under Sec,-,B.&P.C.lie this WATER HEATER W/VE 4.00
reason
Date Owner WATERSYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPI:NSA'1TON OECLARA'rION WATER TR EATIN U 4.00
I hereby affirm that I have a certificate of consent to se t-'
or a certificate of Workers'Compensation Insurance,or a certified r ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 V�❑,x Cerlifed copy is hereby furnished.
Z Z A Cer I 'opy is f w the ci inspec i n Division. FIRE SPR INK ENERGY L24
O APPlican _ MISC.-' REFER TO ORD. y ❑ N❑ v ❑ N❑
CC rn - PERMIT ISSUANCE 6.00 l
� CERTII%CATIi OF EXEMPTION FROM WORKERS' 6 '- FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG C NT r No. PLG.
CLCI (Phis Section need not be completed if the permit is for one TOTAL /��� Y❑ N❑ V F] N❑
DO hundred dollars IS 100)or less.)
I certify that in the performance of the work for which this per- FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner sn us to DTV. M ANICAL PERMIT FEE
O W become subject to the Workers'Compensation Laws of Calilornia.
LU Datn Applicam ALTER OR ADD TO MECH. 4.00 BUILDING
>- rn NOTICE TO APPLICANT: II',after making this Certificate of fix
I- ? emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions 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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 ISec MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name H EATI N G U N IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
inforomtion is correct. I agree to comply with all city and coal'try PLUMBING /�
jnonecs and stale laws relating to building coral nletion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
r,rfose-mentioned
eby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
property for inspection purposes.
(We) agree to sive, indemnify and keep hormlesv the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and ex pensrs which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way a •ne agai t said C in consequence of the
gra g of t ert 1. MECH.CONT. LIC.NO. MECH.
`� TOTAL TOTAL
ahn'e of pp e"BOContoctor Date
OFFICE COPY