15949 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION -PERMIT NUMBER
BUILDING APPLICATION & PERMIT C(],A Q
- T ADDRESS CZ., BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 'dI'"' 159,49
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PRONE - ..
CONTRACTOR'S
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
4r UC.No LIGHTING FIXTURES 10.00/1.00
DON1RA0TOPS - PPLIANCES-RESIDENTIAL 4.00 - -
ADORES
T ftg1LL�.� �1� '
Q DQE. PANELS 10.00 -DATE OF APPLICATION '.
ARCRrtECT_�'1f JI\ PLAN CHECK FEEP.C.N.O.
OR �y PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00 . ,
ADDRESS ENG. ��. SPECIAL CIRCUIT 5.00 ^ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ',
aPFucarvrs :MOTORS SEE FEE SCH.
ADOfl E55
L ISERVICE CHANGE 20.00
-4,-02 LICL'NSED CONTRACTORS DECLARATION -
¢u I hereby affirm that 1 am licensed under provisions of Chapter 9 rl P ISSUANCE DATE '
to (commencing with Section 7000)'of Division 3 of the Business and BEG. ELECT. PLG. MECH.
D Z Professions Code my license is in full force' e a
z o= License Class_. Lie.Number _
q ° Datc __Contractor Q� BUILDING PERMIT_
¢ I J
m 0 w ¢ OWNER-BUILDERbECLARATION INFORMATION
woAU MISC.- REFER TO ORD
;0 at I hereby affirm ing Lam exempt from the Contractor's License VALUATION - $/FT.
F LL o a Law,for the following reason.(Sec.7031.5,Rosiness and Professions PERMIT ISSUANCE -
Code:Any ci(yorcounty which regolresa permit loconstruct,alter, ) f�M�
¢ rt ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LI .NO. ELEC. /� {/GSI
e wO¢ requires the applicant for such permit to file a signed statement that S OW , TOTAL PERMIT TO
m he is licensed Pursuant to the provisions Of the Contractor's License
FI> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ��oaa L9, C),-
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE
_a- by any applicant for a permit subjects the applicant to a civil peoulty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of or mine than five hundred dollars($5000.)
- '
❑ 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 an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP -5;Q9 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improves
ments are not intended proffered for Sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 - BUILDING USE,
builder will have the burden of Proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 .
❑ 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. 6.00 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
contrathe Contractor's
suchLicenects Lwituacontrac[or(s)licensed pursuvV to - SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. ;B.&PC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to selhiname. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.)
- Policy No. Company /J -
O Cerlilied Wpy jj hereby fm0hcd. FIRE SPRINK ; ENERGY T-24
Z 2 Cerl�{�II/���c�i� is I the city aspe i n. MISC.- REFER TO ORD. y N y N
O APPIi - - ❑ ❑ ❑ ❑
� y CERTIFICATEOFF-) .MPT16N PROM WORKERS' PERMIT ISSUANCE �- �� FLOOD ZONE ;A.L.U.C.
Lu COMPENSATION INSURANCEP ONT LC 0 PLG. -
0.0. D (This section need not be completed if the permit is for One ..le TOTAL Y F] N❑ Y ❑ N❑
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issueJ,I shall not employ any Person in any manner so a5 to
O become subject to the Workers'Com ensation Laws of California.
0 w Date 1 Applicant p PFEE
7 O°
a ALTER OR ADD TO MECH. 5.00 ��
- } W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00
provisions of the Labor Code, you,must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 1 hereby affirm (hut there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
(he performance of the work for which this permit is issued(Sec.3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NamcHEATI NG UN IT(OV ER 100,000 B.T.U.)9.50
. Lender's Address
/ 7 ----
I certify that l have read this application and state that tocobcve V ENTI LATION F AN NG LE)
information is correct. I agree to comply with all city and county BOILER-COMPl3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING, /�(N
ordinances and state laws.relating to buildin6 construction, and
hereby,authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0008TU1 SEE FEE SCH. MECHANICAL. Sa
above-mentioned properly for inspection purposes. - ✓
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE ✓a CONST.TAX
may in any way accrue against said City in consequence of the
granting of this PCr MECH.CONT. LIC.NO. MECH.
YIMA7 IRUl1 898�� TOTAL /(p TOTAL 6
(gnat rep Apphcan(/Co ctor Date
OFFICE COPY