2176 (2) APPLICANT TO FILL,IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON 'APPL'ICATION,$t PERMIT RM N a� � �
euaowc lf�i
ADDRESS
✓ �BUILDING-ELECTRICAL-PLUMBING-MECHANICAL _
WNEWY PLAN CHECK VALIDATION
NAME OTY. - ELECTRIC PERMIT FEE
p � ONE
CONT Me WGy'H6 ��. �� _ ,OUTLETS-SWITCHES-RECEP 5.00/1.00
uc.No. �� LIGHT.ING FIXTURES - 5.00/1.0 -�
CONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
AOOREss ��.
HmxE PANELS 5.00 ,DATE OF APPLICATION ,.
ARCHITECT a SIGNS 6.00 PLAN CHECK FEE P.C.NO.
'.OR .. H
ENGINEER
Lia NO, ISIGNSTRANS, 3.00
ADDRESS ENc, SPECIAL CIRCUIT 5.00 �� -PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 9"71j
ADDRESSAORE55 MOTORS ,SEE FEE SCH.- j 3
z
'w o O SERVICE CHANGE 10.Op LICENSED CONTRACTORS DECLARATION L '
a v v 1 hereby affirm that I am licensed under provisions of Chapter 9 ,�, O - ISSUANCE DATE
G y (commencing with Section 7000)of Division'3 of the Business and BLDG. ELECT. PLG. MECH.
H H i Professions Code,and my license is in full force and a tictQ.k (f�1 ppp ❑
0 z,m W License Class R ! Tic.Numb
� J 190
o r Date'17i n� a Contractor
P:.� - L
¢ m s st IIP - BUILDING PERMIT
¢ ¢ w OWNF,R-BUILDE R.DECLARATION "- - INFORMATION
X g e w I hereby affirm that I am exempt from the 6motcmr's License MISC.- REF RD
Fu0 J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE k _ .00 -VALUATION $/FT..
Code:Any city or county which requires a permit to construct,alter, .�� l[IC
EE ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. - LIC.NO. ELEC. Ob f� 'V`'
6 c¢ requires the applicant for such permit to file a signed statement that W� ^I-Il II Y (� '' Q TOTAL /�� PERMIT TO -
A w m he is licensed pursuant to the provisions of the Contractor's License �J
Fri
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
at ��1j7
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ F Do the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ;m by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ 1,as,owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do The work,and the.structure is not
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONE). 4.00
Code'.The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 /,OjE� 'S0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
nsentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SVSTEM-kINC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.), 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int .
' S IND CON PB Other
m
prove for purpose of sale.). INDUSTRIAL WASTE INTER'. 20.00 REl ES
❑ El 1:1 11❑ I,as owner of the property,aexclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPR INKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs not apply -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed Pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 rTRACT NO. .PARCEL-NO.
Cl 1 am exempt under Sec. B.&P.C.for this _ WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF-RS'COMPENSATION DECLARATION WATER Tf3EATING-EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, M J ZONING
or a certificate of Workers:Compentei n Insurance,or a ecrtified - ENG.SITE NO.-
.copythereof(Sec.3800•Lab,C.I �( .}yamV1 -Hn
Policy No(' ompany f/0/.4 0 'rr nfw��ML
O ❑ Certified co y is hereby fu niched. �N FIRE SPRINK ENERGY T 24
Z Z ❑ Certifyyjjdj'D py is Bled ith�tq�e y I$spaon division. MSC.- REFER TO ORD.
O Applicant�l ,,/ t.L Aw ��(•� �""^ - V'❑ N❑ v ❑ N❑
CERTIFICATE017 EXEMPTION FROM WORKERS'CC rn PERMIT ISSUANCE 8.00 �•� - FLOOD ZONE A.L.U.C.
LU� >
_ COMPENSATION INSURANCE PLG.coNTR. ❑c.NO. PLG.
- tl o (This section needfnot be completed if the permit is for one 1� 13 1-1 01"1 TOTAL V E] N❑ V [:] N[]
' Z hundred dollars(S100)or less.) I _
U O 1 certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit,is issued,I shall not employ any person in any manner so as to
W BUILDING
become subject to the Workers'Compensation Laws of California. ✓
y Date Applicant
O
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE, -
C„) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I 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.•
p - HEATING UNIT(TO 100,000 B.T.U.) 4.00
3097,i-Is Nam .
Lender's Name' HEATING'UNIT(OV ER 100,000 B.T.U.)7.50 'ELECTRIC
Lender's Address
I certify that I have read this application and stuto that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and - _
hereby authorize representatives of.this city to enter upon the g01 LER-C P. love,100,000 BTU)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 v CONST.TAX
may m any way accrue against sat City in consequence of the PERMIT ISSUANCE 3.00
grantin Of this permiL MECH.CONT. - LIC.NO. MECH. C''�L
I,(/a r'YIP r�Y'� r 61 074 C6 OTAL � TOTAL
Signaurt Appl cant/ ontracto, Date
OFFICE COPY '