15402 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B1 LDING PROJECT IDENTIFICATION -PERMIT NUMBER
BUILDING APPLICATION & PERMIT 15402
ADD Es BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
(`"AME ��JJTY. ELECTRIC PERMIT FEE
• J HONE( G-5-
CONTRACTORS
OUTLETS-SWITCHES-RECEP 10.00!1.00
Q l- l r JJ„F ,uc.NO. SU.�7�8 t ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00 '
ADDRESS � •, n
r`0CNE �7��/JS PANELS 10.00 DATE OF APPLICATION '
OR” PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
0:1L Mc b 111 SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
AOD•R—E1ss SPECIAL CIRCUIT 5.00
/ L GOL VFizhP.+J. EMP.METER OR POLE INS. 20.00 n
APPLICA r'$
ADDRESS MOTORS SEE FEE SCH. --lie If �Y'�"
SERVICE CHANGE 20.00 p.d
M O LICENSED CONTRACTORS DECLARATION +s AA '
Ix u U I hereby affirm that I am licensed under provisions of Chapter 9 NCE DATE
H< m (commencing with n
Section 7000)of Division of the Business and FtT. 1 PLG. I MECH.
H y z Professions Code,an y license is in full tor�S,,r.,aprgqyy f
G0 w o License CI Lic.Number 4 �. _
2 zo J Date Contractor
a u - BUILDING PERMIT
Gtic
a u OWNER-BUILDER DECLARATION INFORMATION
X 3 LL y 1 hereby affirm that 1 am exempt from the Conlmcsor's License MISC.- REFER TO ORD — VALUATION SIFT.
HLLOa Law for the following reason.(Sec.703L5,Businessund Professions PERMIT ISSUANCE _ t9;6@ -
Code:A ny city Or cc arty which requires a perm it to construct,alter, a(� 000
Qw Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
O LL, requires the applicant for such permit to file a signed statement that TOTAL O� PERMIT T
wm he is licensed pursuant to the provisions of the Contractors License
i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ' /.V'TC.Q/Q/�
)- z a'.' Business and Professions Code)Or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
m r a- the basis for the alleged exemption.Any violation of Section 7031- STORIES TYPE CONSTR.
a;, by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 �'
of net more than five hundred dollars(55001.): -
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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 F IXTUR ES-PER TRAP 5.00 Q So FT.FLOOD ADE. TOTAL ACREAGE
it 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-i INC.4 OUTLETS 6.00
r r improvement is sold within one year of completion,the owner-
0 GAS-EA.SYSTEM-OVER 4 IEA.) 2,00 BUILDING USE
builder will have the burden of proving that he did not build or im-
RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with. 01 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,BusinessLAWN 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 IEA.) 1.00
contracts for such projects with a contructons)licensed pursuant to SEWER-$ANITAR V-STORM EA.200ft/10.00
the Cenlract.,s License Law. TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 6.00 -
reason
Owner Date WATER SYSTEM - 5.00
ACC.DATE -ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP- 5.00 ,.
I hemby.athr r that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,, a certified ZONING ,ENG.SITE NO.
copy there S .3 00,Lab.C.)..tf �fuK Ol
Policy N Company 37
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z� ❑ Cerlifi py Fled*+�Ith CRary inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y❑ N❑
O AOPIICanI CC
X vi PERMIT ISSUANCE �•'
Ou CERTIFICATE EXEMPTIONATIO1°ROMWORKIiRS' FLOOD ZONE A.L.u.L.
W >_ COMPENSATION(NSU PLG.CONTR. LIC.NO.
d PLG. L`/ [3E] C] ❑
� (Paif the his section need not be completed if the permit is for one TOTAL O Y N Y N
D Z hundred dollars(5100)or less.)
U 0 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL-P mit is issued,1 shall not employ any person in any manner so as to
U, become subject to the Workers'Compensation Laws of California.
Q y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING Q
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
"' H ? emptlon,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 provisionsor this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 100MC.F.M.) 6.00 SEISMIC FEE �4
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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
(certify thaticorrect.
readthisapplication and all c that d county VENTILATION FAN (SINGLE) 4.00
information n cstateL I agree to comply with all City and county PLUMBING
ordinances and stole laws relating to building construction, and BOILER H.P.Of 100,000 B.T.U.) 6.00
hereby, authurizc representatives of this City to enter upon the BOILER-COMP(Over IOO,000BTUISEEFEESCH. MECHANICAL OTA '
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORO.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
May in any way accrue against said City in consequence of the PERMIT ISSUANCE
(a
gran
��RL�/(this p rmil. MECH.CONT. LIC.NO. MECH. (�
V >-l ✓�iI/Id- ����{ TOTALTOTAL p`,JFO ,
ignatum of Applicant/Contractor '-DaRe
OFFICE COPY
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