3224 (2) APPLICANT TO-FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN•ON
BUILDING PROJECT IDENTIFICATION vfl UM ER
BUMOINc APPLICATION & PERMIT _ ^� n .
T
(O C90 ry BUILDING -ELECTRICAL-PLUMBING-MECHANICAL V
OWNER'S /' PLAN CHECK VALIDATION
N�fJI C.ruZvHONK'e 7j3-(6B TY. ELECTRIC PERMIT FEE
3 q
CONTRACTORSc�-;,1 UTLETS-SWITCHES-RECEP 5.00/1.00
T• ./'i1J6s� FFK l ,N� ILIGHTING FIXTURES 5.00/1.00
CONTRACTOR'SADDRE APPLIANCES-RESIDENTIAL '4.00
v'LO / C SIJ e:I.fJ�yTE PANELS 5.00 DAT OF APPLICATION --
ARCHITECT SIGNS 6.00
ENGINEER PLAN CHECK FEE P.C.NO.
OR
' uc.NO. SIGNS TRANS. 3.00
ADDRESS ENG. _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
• ZIP EMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. L
ADDRESS/F/^ 1
�1oS SERVICE CHANGE 10.00
Doo LICENSED CONTRACTORS DECLARATION
IcV U - I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
asa a, (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
r m z Professions Cod an�n icense is in full for arWtf!!�. _ ❑ ❑ ❑
z 0,A 0 License Class Lic.Number 77��
9 T r w Date * Contractor _ -G
P: PPILDING PERMIT
Ir: a a OWNER-BUILDER DECLARATION
a a v INFORMATION
w ; u I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
:HLLoa Law for the following reason.(Sec.7031.5,business and ProfessionsPERMIT ISSUANCE 6.00vµupTl
,Aw Code:Anycity or county which requiresa permit toconstruct.alter, ELEC.CONTR. LIG NO. e21O-�)ID
le au Q p Improve,demolish,or repair any structure,prior to its issuance,also ELEC.
n wDLL requires the applicant for such permit to file a signed statement that TOTAL n._.-. 0� fsBg(yryp���p
$a he Is licensed pursuant to the provisions of the Contractor's License IaIFLI/-r N NSI
Hi>
Law(Chapter 9(commencing with Section 7000)of Division3ol'the /4L�P(,q 6�
a Business and Professions Code)or that he is exempt Iherefrom and OTY. PLUMBING PERMITFEE
IS r $ the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
a3 by any applicant for a'permitsubjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(8500).):
❑ 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 It
is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
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 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself epts re through his own employees,provided that such improve-
himself a not through
or employeeffered for sa provided
thathowevsuch
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement issold within one year of completion,the USE
owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING
builder will have the burden of proving that Ise'did not build or im- RES IND CNG PB oma,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑' .❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PAHCEL NO.
and Professions Code:The Comr.clor'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
contracts forsueh projects with a contractor s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCELNO.
❑ lam exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I 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.I � ((,,,,���� � /A/'r, ,.
Policy No. Company_d¢[t�l4CA
O � ❑ Certified copy is hereby furpidRal. FIRE SPRINK ENERGY T-24
❑ Certif-us�(jn:opy is'fi 'T ` tl e ci pection division. MISC.- REFER TO ORD.
Z 0 APPlicadt - Y ❑ N❑ Y ❑ N❑
~ rnROPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CERTIFM WORKERS'
ICATE OF EXEMPTION
ILL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 (This section need not be completed it'Che permit is for one TOTAL V❑ N❑ V ❑ N❑
Z hundred dollars IS 100)or II - '
U 0 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
Ly mil is issued,I shall not employ any person in any manner so as to
L,)* become subject to the Workers Compensation Laws of California.
> y Date Applicant, ALTER OR ADD TO MECH. 4.00 - BUILDING
} N
NOT CF.TO APPLICANT: If,after making this Certificate of Ex-
F Z 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 eaf'�"'
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3,00 yam,
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT(OVER 10000C.F.M.) 5.00 SEISMIC FEE ii
'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
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with alLeity and county PLUMBING
mlinances and state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
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 CONST.TAX
may in any way accrue against saiSLSity in consto a of the PERMIT ISSUANCE 3.00 _
granting of lh' permit. MECH.CONT. LIG NO. MECH. OO
O TOTALof 6(41 TOTAL j
a
Signature o n/ oNracror a
OFFICE COPY