4112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
• 0"BU1 LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGiy� ,e. /✓�v6APPLICATION & PERMIT 4112
ADDR E
E O BUILDING -ELECTRICAL-PLUMBING-MECHANICAL -
NER'S PLAN CHECK VALIDATION
" ME PH0NE157"70
CITY- ELECTRIC PERMIT FEE
Ll
�
L NTRACTOR'S ,1^
NAME E17f1 OUTLETS-SWITCHES-RECEP 5.00/1.00
11040 is �bILIC.NO.qX LIGHTING FIXTURES 5.00/1.00
FARCHTECT
TRACTOR'S PPLIANCES-RESIDENTIAL 4.00
HESSIMI PHONE PANELS 5.00 DATE OF APPLICATION
IC� - SIGNS 6-GOPLAN CNECK FEE P.C.NO.
NEER
" 1.1 - SIGNS TRANS. 3.00
nooAEss E" �D fJ
SPECIAL CIRCUIT X5.00 PERMIT VALIDATION
EMP.METER OR POLE INS. 15.00 p
APPLICANTS MOTORS SEE FEE SCH.
� ADDRESS b1
SERVICE CHANGE 10.00 � a J
Foo LICENSED CONTRACTORS DECLARATION
1 u<ya. I hereby affirm that I am licensed under provisions of Chapter 9 - 'ISSUANCE DATE
a a (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. '.PLG. MECH.
r D w Professions C e, license Is in full for a d f ❑ ❑ ❑
z O `v{' - License ss Li, Numb _ _
F In t D Datc �Contmctor H- P
F x s BUILDING PERMIT
rc
X.< OWNER-BUILDER DECLARATION
o d ea MISC.- REFER TO ORD INFORMATION
E
; N ' I hereby affirm that I am exempt from the Contractor's License TION $/FT.
� u0er Law for the following reason,(Sec.7031,5,Businessand Professions PERMIT ISSUANCE 6.00
MTHI
Code'.Any city or county which requires,permit to construct,alter, �� 000
Q a Q 0 Improve,demolish,Or repair any stroal me,ptior to Its Issuance,also ELEC.CONTR. LIC.N0. ELEC. /s
0,
requires the applicant for such permit to file a signed statement that TOTAL Cit Of PERMIT
E
$m he is licensed pursuant to the provisions of the Contractor's License
rZ �
Law(Chapter 9(commencing with Section 7000)n f Division 3 ofthe �Pj�iN6$4• �'B/f//X/
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aF, by any applicant for a permit subjects the applicant too civil penalty ALTER'-DRAIN -WATER (EA.14.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of rhe 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 or through his own employees,provided that such improve p �✓
mends are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner.
buildGAS-EA.SYSTEM-OVER 4 (EA.) 100 auttDlNG USE
middle,will have the burden of proving that h .
e Alit nor build or int. RES IND CON PD Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER, 20.00
C] 1.as owner of Ode property,um exclusively contracting with ❑ ❑ ❑ Cl ❑
licensed contractors to construct ilia project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contr:emu's License Law docs not amply
to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00 5�6 -•(`L 9
contracts for such projects with a contracmds)licensed pursuant to
me Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.ria this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKF-RS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-Insure. ZONING
or a certificate of Workers'Com pens ion Insurance,or a certified ENG.SITE NO,
copy thcrcoff Sec.3800,Lab.C.). /�
O P IicY No. Company - _ .A, ,
erl�- ttw- Ld, FIRE SPRINK ENERGY T3A
❑ Certth y mspecuon lesion' MISC.- flEFER TO ORD.ZQ Applicant V❑ N Y ❑ N❑
fr NCERNPR \1 WORKIiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
.d O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
', Z handrail dollars IS 100)or less.)
U 01 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F" mit is issued, 1 shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
CL Dee Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /9S�
} to NOTIC17 TO APPLICANT: If,after making this Certificate of Ex-
emption,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 he deeaned revoked. AIR HANDLING UNIT(TO 10)000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 5.00 SEISMIC FEE ��70
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 Name
Lender',Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3,00
information is correct I agree to comply with all city and county PLUMBING'
ordinances and state laws relating IO building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
ahove-mentioned property for inspection purposes. BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. aQ
Cupertino ,ginned liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX 3 06
may in a y way ac m a ,lost said 'dy in consecu mce Othe
granting f this p ti MECH.CONT. LIC.NO. MECH.
p4 TOTAL TOTAL 3/3.
I t e u plian [ P iru
are 6�=
OFFICE COPY