1028 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL
11PE NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT 1028
BDILOING
ADDRESS V 1 S6 R
-/ W0O()?U -/ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
"AM DTV !' -+ ° ELECTRIC PERMITm� `„�,-,:a_r 7FEEr,
s • r�I�ll�a�,{ PHON J� �/ • IV t i } lie MJ~L l'T�F .w..7
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
AME 7
1'?oC
(_i&WtLIC.rvo.V4�q•S•� LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS ^^ yF
111 PHONW(J�t PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' LIc.No. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00 ^
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS
SERVICE CHANGE 10.00 p
M o LICENSED CONTRACTORS DECLARATION �a
¢ u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANC GATE
H Q j (Commencing with Section 7000)of Division 3 of the Business and PERIN BLDG. ELECT. PLG. MECH.
7% Professions Cod a license is in full for�f,,gn e(re a CU rvr
0 us4a- License Clas Lic.Number�] 9 ❑ ❑ ❑
Z
w Dale Contractor
xSEPerr *e�'BUIL'DING P,ERMIT�*r�',',1
¢w OWNER-BUILDER DECLARATION Syk3,a;J,VANFORMATIDNWIIPOo
I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
IA w p VALUATION S/FT.
uo4 Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 lO,/N, edl7
Code:Any city orcounty whichrequiresa permit to construct,alter. L.JJ �T'l'
c < FO improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
C c¢ requires the applicant for such permit to file a signed statement that TOTAL ��jj���� PERMIT TO
w m u. he is licensed pursuant to the provisions of the Contractor's License I „. _ x.. .^N`r, -�° •t"g;''":"' • ILt-J1_
>
Law(Chapter 9(commencing with Section 70001of Division 3 of the y�x NSF .w`t'` 'N a-= ✓� {
r 4 Business and Professions Code)or that he is exempt therefrom and QTY is 15.4 ,,PLUMBIND PERMIT,3,+(' a '1>• Cs FEE CLs't1�(t� 5 5
fro p ti ��N� '�� ;k%�;.x1"sYt ,..'2�..^, r . :.f M-. STORIES TYPE CONSTR.
¢ $ the basis for the alleged exemption.Any violation of t(on civil
enol 5 F;` F -
i ; ,.
by any applicant for ivchcno,dd.subjects $5OO).licanl mgcivilpenahy ALTER-DRAIN -WATER (EA.) 4.00 I
of not more Than five hundred dollars(55001.):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 SEE FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. f�
ments are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 A4
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.G0 BUILDING USE
builder will have the burden of proving that he did not build or IT. RES IND CON PS one,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrxctono licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.B.&P,C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. . 4.00
l hereby affirm that l have a certificate ofcomrnl to self-insum, ZONING ENG.SITE N0.
or a certificate of Workeri Compensation Insurance.or a certified
copy thoof✓ ;6Lab.C.).
QPolicy NpanY
,CR( 2'-A$
R Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifie co Is Jed uh the city inspection division.
_ MISC.- REFER TO ORD.
O Applicant V E] NE] V ❑ NE]
CC ti CERTIFICATE OF EXEMPTION FROAI WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, V❑ N❑ V ❑ N❑
d O /This wclidn need not be completed if the permit is for one TOTAL
� Z hundred dollars IS 100)or less.) z;,r
U O 1 certify that in the performance of the work for which this per,
Y r ve 4t FEE SUMMARY
LL {- mit is issued,I shall not employ any person in any manner w as to OTY' MECHANICAL'PERMIT I 'FEE ak.,•. -- .,a:r.
O W become subject to the Workers Compensation Laws of California. '3L `
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING r a ra
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
1... z emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you muss forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10. 00C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE 4 0
1 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.E 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 that l have read this application and sl ate that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state Paws relating to building construction, and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 B7U)BEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.' REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit. -LIC.NO. MECH. -i
TOTAL TOTAL I' All
Signature of Applicant/Contractor Date
OFFICE COPY