5597 (2) 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION
aOtLDING - APPLICATION & PERMIT PERMIT NUMBER
A REaa
UILDING-ELECTRICAL-PLUMBING-MECHANICAL 5597
PLAN CHECK VALIDATION
` "En �7► i/ OTaY .41.°"' rY�s`n .If'`ELECSRICtPERM1T is Js.`.�7 b+`+ ;,kFEE,.
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PHONE
N EA �'��• OUTLETS-SWITCHES-RECEP 5.00/1.00 ,
O,IleLIGHTING FIXTURES 5.00/1.00
APPLIANCES:RESIDENTIAL 4.00
P O PANELS , 5.00 DATE OF APPLICATION
ARVITECT. SIGNS 6.00 PLAN CHECK FEE P.C:NO.
o
E EE .
LIc. SIGNS TRANS. 3.00
A(A. G. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zIPrrEMP.METO OL I 15.00 '
APPLICANTS MOTOR
S • SEE FEE SCH.
AOOREss
SERVICE CHANGE 10.00
D o LICENSED CONT RACTORS DECLARATION
<i U I hereby al Iiml that I am licensed under provisions of Chapter 9 �Z Li O L 00 ISSUANCE DATE
Icomnrencmg Ith.c tion 7000)of Division 3 of the Busin•ss and
G <A BLDG. ELECT.I PLG. MECH.
H N w Professions ry license is in full r ,i�f�.
Z o w Liansu Clas. Lic.Num J ® '�
9 z - ° ale_ Contmclo
yHW
7 �f BUILDING PERMIT
aw OW Ii -BUILDER DECLAR TION ^INFORMATION 'a_y 7`
X ;d G I hereby infrm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H
U. Law for the followingreason.(Sec.7031.5,Business and Professions . PERMIT ISSUANCE - 6.00 OU VALUATION S/FT.
Cade:Any city orcounly which requiresa permit to construct,alter, _ pZQ coo
Q¢p improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
i w m u requires the applicant for such permit to file a signed statement that TOTAL OW PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License y^
HiQ
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe SW//L17LllA/�' PLC
4 o Business and Professions Code)or that he is exempt therefrom and OTY. ... .PLUMBING PERMIT FEE'
It H $. the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
T by any applicant fur a permit subjects the applicant toa civil penalty
&
of not more than five hundred dollars(5500).): ALTER-DRAINVENT-WATER (EA.) 4.00
.0 L 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,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 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-1INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 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.l. 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- 1 INC 5 V.B. 5.00 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 3v ra -♦'7- f� 7
contracts for such projects with a Contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1"m exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00 [f.,0 !OS-
mason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of Consent to self-insure, _ ,
or a Certificate of Workers'Compensation Ins o�a Certified p ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lah C.). ` ITl LA,� D d O�-
PolicyNo. Company /1
O erti Copy ish Cby furnishe ^ � FIRESPRINK ENERGYT24
z Car' co lab-wish t cn pCct�q'^ **'pn.
0 pant0v' MISC.- - REFER TO ORD, v❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU CfiRTI19 ATE I: EXEMPTION INS FROM WORKERS'
IL _ need not
be completed if
PLG.CONTR. LIC.NO. PLG, � W ❑ ❑ ❑ ❑
1 hundred
dollars need not be completed if the permit is for one TOTAL V N Y N
0 Z hundred dollars(n the pe Icor)
LL O I certify that h the performance°f the work for which this per- QTY:. ,MECHANICAL PERMIT FEE FEE SUMMARY ;
LL F bee is issued,1 shall not employ any person in any manner so is to
U become subject to the Workers'Compensation Lows of California.
BUILDING
y Date CnALTER OR ADD TO MECH. 4.00
>_ to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I.. ? emption,You sbecome subject to the Workers'Compensation APPLIANCE 4.00 Oxa PLAN CHECK
provisions Labor Code, you must forthwith comply with' FEE
U such provisions
the the Labor
or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQO00C.RM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a Construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
31ek MICROFILM
nce of Dm worfor which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00
097,Civ.C.)
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC �
Lenders Address a .
Icertify that 1,have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00 /
information is correct. I agree to comply with all city and county PLUMBING pZ(O r
ordinances and state laws relating to building construction, and BOILER-COMP(3 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 property for inspection purposes.
I(We) agree to save, indemnify and keep harmless the City of MISC..- REFER TO ORD.
Cupertino against liabilities,judgments, casts end expePses hich PERMIT ISSUANCE 3.00 01C CONST.TAX
may in any w a true again .aid C' in co Ce f the
grantir�lt' PC
iL MECH.CONT. LIC.NO, METH. , p
All
TOTAL ' TOTAL- / Qo
Si u f pplicant Contractor ce '
OFFICE COPY