14062 (2) ITAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
BU I LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
aoD/EBUILDING a APPLICATION & PERMIT ' 14062
l47b G�fi4KSR-) 6. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
�r� �`,a. - OTY. ELECTRIC PERMIT FEE
,4,sL .(y eVI-S ZONE .
CONTRACTORS UTHTLETS-SWITCHES-RECEP 10.00!1.00
AM
NF
G ^ LIC.NOQ, LIGING FIXTURES 10.00/1.00 a -
.
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
A pq 55 I ',x� ,
/14 �yC/� 'PRONE Zj PANELS tO.OU DATE K APPLICATION
ARCHITECT PANELS.(OVER 200 AMP) 20.08 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ARCH.
RENG. SPECIALCIRCUIT 5.00 PERMIT VALI DATION
ADDRESS IIP rEMP,METER OR POLE INS. 20.00
APPLICANrs
ADDDRESSDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 / /p''7
woo LICENSED CONTRACTORS DECLARATION ` %�f�� /
<u v I hereby affum that I am licenud under provisions of Chapter 9 I" ISSUANCE DATE
0 z w (commencing with Section 7000)of Division 3 of the Business and
o rpy [ ' BLDG. ELECT. PLG. MECH.
i Professions Code, I is in NII force.andri/elSn� ❑ ❑ ❑
9 z o License CI Lin.Number J E ! `',,,^ '
H w Dater12Contractor
Y M < OWNER-BUILDER DECLARATION i P.10)05`001BUIL IRM PERMIT
E o d U MISC.- REFER TO ORD INFORMATION
'x ; 1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
'aLa < Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00
r ' Code:Any city or county which requires permit to construct,alter,
G sa Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC.
i iE D Q requires the applicant for such permit to file a signed statement that �7W/4' L�Y ST(�s� TOTAL Q 6 -r PERMIT TO
X he is licensed pursuant to the provisions of the Contractor's License
FZQ Law.(Chapter 9(commencingwith Section 7000)of Division 3 ofthe G
Business and Professions Code)or that he is exempt therefrom and QTY: PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN III 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 an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 other
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ El❑ 1,as owner of the property,am exclusively contracting with 1:1 ID
licenud 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 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
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,BAP.C.for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z 0 Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y N Y NE]O Applicant
~ r2 PERMIT ISSUANCE 10.00 --FLOOD'ZONE A.L.U.C.
LU CERTIFICATE E EXEMPTION FROM WORKERS'
W �_ COMPENSATION INSURANCE PLC.CONTE. LIQ NO. PLG. Y F] N Y ❑ N C]d O (This section need not be completed if the permit is for one TOTAL
=) Z hundred dollars 1$100)or less.)
U O 1 certify that in the performance of the work for which this PeruQTY: - MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued I shall not employ anY person in an' )sal cr so as to
O W become o he Workers' sensation s p 'fggisE
Uate Applicant BUILDING
} rail NOTICE O APPLICANT: If,a ter making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
? 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 iO=c.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read Wis application and stale Ihal the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILEWCOMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property 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 CONST.TAX
may in any way ace a i'at said City in conseque cc of the PERMIT ISSUANCE 10.00
In of lIn CEn MECH.CONT. LIC.NO. - MECH.
g B P
e.t-G �` TOTAL TOTAL
Signature of Applicant/Contractor Da5k -
� OFFICE COPY