0479 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEx Y
f O - RMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
e BOLDING • 0479
A I 1
•OORE55 q] 4 l9
TjIJ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'a PLAN CHECK VALIDATION
NAME - S k OTV. ELECTRIC PERMIT FEE -
0 Cis
Q
vHONE
CONTRACTORS /d UTLE75-SWITCHES-RECEP 5.00/1.00
NAME Q r , 1 00
l7 Wo
.LIC.NO. d LIGHTING FIXTURES 5.00/1.00
co TRACioas ,4,aw APPLIANCES-RESIDENTIAL 4.00 A14ESS �/��/��yc a to
g/IONE _ PANELS 5.00 DATE OF APPLICATION
OqC ITECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER 3.DD
' LIC.rvD. - SIGNS TRANS.
ARC H.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. '
ADDRESS
SERVICE CHANGE 10.00
wo O LICENSED CONTRACTORS DECLARATION Y�0
rt u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN E DAT€
PT (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
as i Professions Co and y 'ansa.is in fully ` O Z . . a ❑
z o�- License C.
Lic.Number ❑. ❑
O - Date Comractor ��,
a Y xJU1, L BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION - INFORMATION
F. 0O MISC.- REFER TO ORD
W3 u H I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
a.Oj Law for the following reason.(Se -
c.7031.5,Businessand Professions pERMIT ISSUANCE - 6.00' /
EN Code:Any city or county which requires a permit to construct,alter,
Q a, Q Q Topic, e,demolish,or repair any structure,prior to Its ISsnancT.also ELEC.CONTR. LIC.NO. ELEC.
i -y'D'¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions ol'the Contractor's License
rii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OT . PLUMBING PERMIT FEE
Or r the basis for the alleged exemption.Any violation ofSection 703 L5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 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 ED,IT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees.Provided that such improve. ....:
mems are through
or employees,ffered for provided
that s the building GAS-EA.SVSTEM-l1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.DD 'BUILDING USE
builder will have the burden of proving that he did not build or im" RES . IND... CON, PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,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
contracts License
Lwithacontmctor/s)Iicensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO.
the Contractor's or such
License Law. PARCEL NO.
❑ 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"%J ACC.FILE NO.
WORK ERS'COMPENSA7'ION DECLARATION WATER TREATING EQUIP, 4.00 '
I hereby affirm that l have a Certificate of consent to self-insure. ZONING ENG:SITE NO,
,.,,
Or a Certificate of Workers'Compvrc1Alion Insular -nr a certil ieJ - -.
copy thereof(Sce.3800,Lab.C.). J"TR? wH �
Polity No, Company (�t'z .
O L1T7ji Certified copy is hereby furnf� FIRE SPRINK - ENERGY T 24
Z Z Certi ' copy'is flea drvHI be.11Uuaspectiun division. MISC.- REFER TO ORD. y N v N
Applicant V�7 .X✓ `r ❑ ❑ ❑ ❑
� � PERMIT ISSUANCE 6.00 FLOOD ZONE A.LLLL.
LUCERTIFICATE OMPENS EMPTINSURAFROM WORKERS' -
l1J >_ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG., '`' '
1 0 ( m
'This section need not be copleted if the permit is for one TOTAL . Y❑ N[:] Y❑ N❑
D Z hundred dollars(S 100)or less.)
L) O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
H mit is issued,'I shall not employ any person in any manner so as to
O u become subject tothe Workers'Compensation Laws of California. BUILDING /
Date Applicant ALTER OR ADD TO,MECH. 4.00 sb•S
} N NOTICE TO APPLICANT: If,after making this Certificate Of
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK -r
provisions of the Labor Code, you must forthwith comply with AIR HANDLING UNIT(TO 10=CF.M.) 3.00 ' FEE
O such provisions or this permit shat]be deemed revoked. -
. CONSTRUCTIONLENDINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 , SEISMIC FEE
I herebypffirm 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(OVER 100,000 B.T.U.)7.50 7 "' -ELECTRIC '
Lender's Address .,
I certify that I have read this application andstare that the above VENTILATION FAN (SINGLE) 3.00 r -
information is correct. I agree to comply with ail 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 BOILER-COMP (Over 100.000 BTU)SEE FEE SCR. .,. _.. ..MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless Die City of MISC.- REFER TO ORD:----- , ----------- - - -
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 s.-' - CONS. T...TAX
... ...... .. ...... ....
may m any way accrue against said City in consequence of the -
grof this ITS Intl. MECH.COOL LIC.N0. MECH.
TOTAL ._.,..._.-,.. ._�..�.�����.... .._.�
Sign re of ApplicanrlComracmr D
_ OFFICE COPY.