7163 (2) • APPLICANT TO FILL IN IN7FATION WITHIN RED LINES - USE •L POINT PEN ONLY
BUILDING PROJECT IDENTIFPERMIT NumRER
BUILDING , APPLICATION & PERMIT �� 63
40CRESSUBUILDING-ELECTRICAL-PLUMBING-MECHANICALOWNER'S . - . PLAN CHECK VALIDATION
LECTRIC•PERMIT• ' FEE
NAMERAcroR's UTLETS-SWITCHES-RECEP 5.00/100
G uc.No. �OL'� LIGHTING FIXTURES 5.00/1.00
C.NTRA OR'S
AAD/DRESS �%� �] yy•''�y1 PPLIANCES-RESIDENTIAL 4.00
pC¢ ShalPHONE �7-�J/r PANELS. 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
o
I ENGINEER��j' nn'' ,�y ��,,,/ -
V e/� LQc�2.Slfl�IQGaD. SIGNS TRANS. 3.00
AR.SS END. PERMIT VALIDATION
ADDRESS / SPECIAL CIRCUIT 5.00
zip C14YII TEMP.METER OR POLE INS. 15.00 5Q0 �0
ADDRESS MOTORS SEE FEE SCH.
ADDRESS _ ��/
LQ lDy/gs um SERVICE CHANG 10.00 �`-
0
,02 LICENSED CONTRACTORS DECLARATION -
rt u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Hm (commencingwith Section 70001 of Division 3 of the Business and
H N-'^ Professions Code,a 1 liCmhae is in full force' �(fect.�y BLDG. ELECT. PLG. MECH.
z i a License Chis Lie.Number 6 -1(IO ❑ ❑ ❑
o r Date_ Contractor of Cupar
a r f J BUILDINGRERMIT', „nz
a ¢ OWNER-BUILDHR DECLARATION " {+
ED.. MISC.- REFER TO ORD INFORNIAT-ION'.'a 5.'.''�'
y 1 hereby affirm that 1 am exempt from the Conlmctor's License VALUATION S/FT.
F LL 0 J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
mm Code:Any city or county which requires a permit to construct,alter,
- a
rt In Q improve,demolish.or repair any structure,prior to its issuanCe,also ELEC/.CONTR. L LIC/NO. ♦q /y� ELEC. J
e wO u requires the applicant for such permit to file a signed statement Thal ✓ //O (�PGIYrG /��1 f� V TOTAL a./ �� PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the TEMP ':-7
Business
m o Business and Professions Code)or that he is exempt therefrom and CITY. ,PCUMBIN6 PERMIT? 'gFEE',I x
'
te
I m tire basis for the alleged exemption.Any violation of5ec(ion 7031.5 " STORIES TYPE CONSTR.
e-3 - by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not mare 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 docs such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Rents are nolintended oroffered for Sale.If,however,the building GAS-EA.SYSTEM-1.INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SV STEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES 1N0 ON PB Olner
P
for purpose of sale.). INDUSTRIALWASTE 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
contracts I'or such projects with a contmclots)licensed pursuant to
the Contmcmr's License Law. SEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,R&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
coPY lhers It e .;ab,Y.). f74L1 G W7M1'6n .
`�1/ Policy N<. om tan
Q / ❑ Certiliedcopyisherchyfuinished. FIRE SPRINK ENERGY T 24
Z Z ':K'Cerhfie � I fd
OApplicantsfMZA!"l
MISC.- REFER TO ORD. 'Y ❑ N❑ v ❑ N❑
~ LO / PERMIT ISSUANCE 6.00 FLCODZONE A.L.U.C.
•CERTIFICA'1'1;OF EXEMPTION In ROM WORK SRS'
W _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO.
CL O ITIRS section need not be completed if the permit is for one. TOTAL Y❑ N❑ Y❑ N❑
0Z hundred dollars(5100)Orless.) r
U O I certify hot in (be performance of the work for which this per- - MECHANICAL PERMIT FEE FEE SUMMARY
UI- mit b Issued,I shall not employ any person in anymannerso asto U become subject to the Workers Compensation Laws ofCalifornia.
tU Date Applicant - - BUILDINGa ALTER OR ADD TO MECH. 4.00} t0 NOTICE TO APPLICANT: If,after making this Certificate of Tumption,you should become subject to the Workers'CompensatinAPPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
suh provisions or thi's permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby afirm that there is a construction l6oling agency furEXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT 100,000 B.T.U.)7.50 ELECTRIC
,Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
in
is correct.I agree to comply with all city and county PLUMBING
BOILER•COMP(3 H.P.Or 100,0008.T.U.) 4,00
ordinances and state laws relating (o building construction.and
Iv 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.
'1 (We) agree to save, indemnify and keep harmless the City of -MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence'of the
grantin of this permit MECH.CONT, LIC.NO. MECH.
X3 TOTAL TOTAL
Sign u e Appl 'ant/ one Rector Da
OFFICE COPY .