9407 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
LDING PROJECT IDENTIFICATION PERMIT NUMBER
II,LGING - APPLICATION & PERMITalIg 407
ADDRESS ,. �/
O a�•S^' /�IMaN , BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME
� NONE DTV. ELECTRIC PERMIT FEE
P
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10,00/1.00
1A,141141LIC.NO. O/,'' / LIGHTING FIXTURES 10.00/1.00 ,.0
CONTRACTOR S AppREu PPLIANCES-RESIDENTIAL 4.00
/
/ Ni>A AYE.PNONE 'y/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. PAID 3.00
noa Ess ENc' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER L 20.00
ADDRESS -MOTORS EE SCH.
A
PPLICA
SERVICE SHAof 20.00
w w LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a i w I herehy affirm that I am licensed under provisions Of Chapter 9 ISSU A
< e (commencing with Section 7000)of Division 3 of the Business and e D ELECT. P
F y i Professions Code,a d my license is in full fore nd effe L ❑
o z w C License Clas •�a LiC.Number /es
r w Date- gT/��3 Contrac[Or -i.
¢ ie Q a OWNER-BUILDER DECLARATION BUILD
rc a u INFORMATION
ww I hereby alto. that I am exempt from the Contractor's License MISC.- REFER TO ORD
H u o se Law for the following reason.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE 10.00 Q /VVALUATIIOONN E/FT.
,A m Code:Any city or county which requires a permit to construct,alter, I V
a a ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEL.CONTR. LIC.NO. ELEC.
i O LL requires the applicant for such permit to file a signed statement that TOTAL V pE O
w y he is licensed pursuant to the provisions of the Contractor's License
HZ> Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE -
M Is-$ the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
T by any applicantfura permit subjects the applicant toa civil penalty , ALTER-DRAIN&VENT-WATER (EA.) 5.00
Of not more than five hundred dollars(5500).):
❑ I,as owner of.the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to in owner of '
property who builds or improves thereon,and who does such work ;I.. FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.-If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 '
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or im- . . . E IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑ ❑ El Las owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 1 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/ 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION I WATER TREAT I 198b 5.00
I hereby affirm that 1 have a certificate of coroent 10 self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy there (Sg_09,Lab�.l. ��e,A - Qf VvQ (R
Policy No %l�rrd$ y.) i14A c1tv
❑ Cemfie e'Davis here yfurnished. FIRE SPRINK ENERGY T 24
Z ❑ Iffier y4 ii�"ith the citys ins ection division. MISC.- REFER TO ORD.
O_ Ag Can x N%- �/ Y ❑ N[3 Y C3NE]
C 'R I KATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOODZONE A.L.U.C.
LU COMPENSATION COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLO
TOTAL 30 Y❑ N❑ Y❑. N[:]CL Z (This section need not be completed if the permit is for one
U O hundrecidollars(5100)orless.)
I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL t mit is issued.I shall not employ any person in any manner So as to
O Wbecome subject to the Workers'Compensation Laws of California. 50
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
Q.
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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.) 4.00
CONSTRUCTION LENDING AGENCY r, .AIR HANDLING UNIT(OVER 10000C.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CW.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name IHEATI NG UN IT'IOVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC Q
I certify that I have read this application and state• that the above VENTILATION FAN (SINGLE) 4.00 d _information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 8.00
hereby an thorim representatives of this city to enter upon Ilse 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City oI' MISC.- REFER TO ORD.
Cupertino t liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in y w accrue against said City in consequence f the
granlln rmi. CH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
Sign ur of Applican O edG Date
OFFICE COPY