0338 (2) A IN RED LINES - USE BALL POINT P N ONLYGG
PIiPPLICANT TO FILL IN INFORMATION WITH
PEVNI/T NUMBER
BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING
ADDRESS tizil45
1BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 0338
OWNER S PLAN CHECK VALIDATION
NAME CITY ELECTRIC PERMIT FEE
CONTRACTOR S
NAME UTLEL -SWITCHES-8ECEP 5.00/1-00
LIC,NO. 1� rLFGHTI NSG �IXTURES 5.0011.00
NTR FOR S
-FODDRESS P PLIANCES-RESIDENTIAL 4.00
PHONE PANELS DATE OF APPLICATION
ARCHITECT t9i"o 6�00-00 PLAN CHECK FEE P.C.NO.
OR SIGNS 03VI-1,
ENGINEER LIC�NO SIGNSTRAW.' 0
PERMIT VALIDATION
ARCH.OR ENO TrIGM N00
SPECIAL CiRiNaf
ZIP TEMP.METERybW POLE INS. 1 5.00
APPLI CANT'S MOTORS EE FEE!3CH. Ir
ADDRESS
SERVICE CHANGE 10.00 �441
Zi
02 LICENSED CONFRACTORS DECLARATION
I hereby affirm that I am licensed under provisionsof Chapter 9 ISSUANCE DATE
--TELECTTPLG MECH.
('mramocing With Section 7000)or Division 3 of the BuSinCis and _.L.G
Professions Code,and my license is in full force and effect. [:E:l
d License Class-Lic.Number
D.te-Cont,.cto,-
BUILDINGPERMIT
a: OWNER-BUILDERDECLARAIION INFORMATION
& DID License MISC.- REFER TO ORD
X 3: A- I hereby affirm that I am exempt from the Contractor's VALUATION $/FT.
lo Law for the following reason.(Sec.7031.5,Business and Professions 6.00
Codc:Any city or county which requiresa permit to construct,alter. �/"--o
O< PERMIT ISSUANCE
a,> 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC-NO LEC.
, 4 0 E & 00
iL 0 requires(he applicant for such permit to file a signed statement that 1TOI PERMIT TO
la As he is licensed pursuant to the provisions of the Contractor's License
> Law(Chapter 9(commencing with Section 7000)of Division 3 of the 4,3 0/7*,-0 A/
2 40 Business and Profes,lions Code)or that fie is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS the basis for theldleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
x% 1,as owner of(he property,or my employees with wages as
their sole compensation,Will do the work,and the Structure is net BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP R ES.UNITS
intended or offered for Sale(Sec. 7044, Business and Professions DRA I NS-FLOOR,ROOF,AR EA,CON 0. 4.00
Cocci The Contractor's License Law does not apply to an owner of -
property who builds or improves thereon,and who does such work F I XTUR ES-PER TR AP 4.00 FLOOR ARE. TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
ments are not intended or Offered for Sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
Or Improvement is sold within one year of completion, the owner-
builder will have the burden ol proving that lie did not build or in, IGAS�EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
1 0 1, a owner of the property,ino xdu,isely�cmtnctin,with Q El 0 0 El
licensed contractors to construct tile project(Sec.7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
.oil laurcumas Code The Contractor's License Law does not apply
to an owner of Property wind holds or improv�thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects will]a COntractons)licensed pursuant to SEWER-SANITARY-STORM EA 200ft/800 TRACT NO, PARCEL NO.
the Contractor's License La..
0 [am exe.;.Pt;dCJSec._,B.&P.C.for this
WATER HEATER W/VENT 4.00
reason la
Date S- WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have 3 celtifielltv of consent to self-insure, ZONING ENG.SITE NO.'
or a cerlificate of Workers*Compensation insurance. certified
copy thereof(Sec.3800.Lab,C.).
Policy No-Company.
0 0 Cerjified copy is hereby furnished, FIRE SPRINK ENERGY T-24
Z Z 0 Clutifil,d copy is filed Willi the city inspection division. MISC. REFER TO ORD.
0 Applicant- Y El N F] Y [] NEI
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00) FLOOD ZONE A.11,.U.C.
`E
LU > COMP17NSATION INSURANCE PLG.CONTR. �LIC.NO. PLO
CL 13 OTAL Y E] IN[] Y
(This section need not be completed if the permit is for one C:]
D Z hundred dollars(S 100)0,less)
L) 0 1 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
0 U bccor!Scsji.b�jecto Lthe Workers California.. - BUILDING _b
M. Apple ALTER OR ADD TO MECH. 4.00
I ICE 0 or Ex
CE 0 LICANI a te,making tus CA,�
It
ion�s
empnon,you should become subject to the Worker,'Compensation APPLIANCE 4.00 PLAN CHECK
ovesions of the Labor Code. you most forthwith comply will% FEE
In
such provisions or this Pconit sh.11 be deemed revoked. AIR HANDLING UNIT ITO IOPMC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby at I'm that there is a ccinx�r .in lending agency for EXHAUST HOOD(WITH DUCT) 2.00 MICROFILM
the perfomarc he W%f.,,W,hlct cAtt is issued(sec. HEATING UNIT(TO 100,000 B:T.U.) 4.00
3097,Civ.C.). % A,
Lender's Nam
Lender's Addr H EATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
A
I certify that I have read this application and sta!t tlh�abvuoe --fVENTILATION FAN (SINGLE) 3.00
information,,, correct. I agree to comply.with all city and county -7P F13t H 4.00 PLUMBING 01
ordinanc it State laws relating to building construction, an, OI�LER P.or.1 00,000 B.T.U.) -
e' t B, 0 L
hereby authorize representatives of this city o enter upon ic LB ER COM Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep homeless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments. costs all. s,v,.s.s Which CONST.TAX
may i Wit ace inat Said City in con+qu�ncp of the PERMIT ISSUANCE 3.00
r is cuai,V, ECH.CONT. LIC.NO. MECH.
M TOTAL TOTAL Ig' 00
SiRnal-un,of A ;lot OFFICE COPY 09