15535 (5) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILowG APPLICATION & PERMIT .� �[���
Dun SEE
ZLu c1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1,
WNER'S • PLAN CHECK VALIDATION
s+'t,`•� NAME 1 OTY. ELECTRIC PERMIT FEE
=� Name AcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00 /
LIC No. LIGHTING FIXTURES 10.00/1.00 _
CON78ACTOR�s � - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
.� ARCHITECT PANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE -' - P;G NO.
OR
ENGINEE
/3 SS, LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. t 5,00 PERMIT VALIDATION
ADDRESS / SPECIAL CIRCUIT .
�a�1f+p d zlv EMP.METER OR POLE INS. 20.00
aDERESS11LICATs/ygg/ allgel3 `j�r MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 C-/ [.
Ca o o LICENSED CONTRACTORS DECLARATION J/� l Q
rv u I hereby affirm that 1 um licensed under provisions of Chapter 9 ISSUANCE DATE
z w (commencing with Section 7000)of Division 3 of the Business and
y Q ,An - BLDG. ELECT. PLG. MECH.
F O z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
oz=W License Class Lic.Number
E,t Date Contractor
a >< s BUILDING PERMIT
r a ec a OWNER-BUILDER DECLARATION RATION :,,
FORMATION
woAU MISC.- REFERTOORD
; 1 . 1 hereby affirm tial I am exempt from the Contractor's License VILTION $/FT.
H u
O< Law for the following reason.(Sec.7031.5,B.Nnessand Professions PERMIT ISSUANCE 10.00 Code:Any city or county whichi egairesa permit to construct,alteqin 2¢40improve,demolish,or repair any structure,prior lO its Issuance,also ELEC.CONTR. LIC.NO. ELEC.¢ requires the applicant for such pernih to file a signed statement that TOTAL ERMIT TOw mhe is licensed pursuant to the provisions of the Contractor's LicenseQLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FGL� K�
M h c� the basis for the alleged exemption.Any violation of Section 7031.5 Vs'• STORIES TYPE CONSTR,
i ; _ by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
4 ( of not more than five hundred dollars(5500).):
❑ I,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 at offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
r In, Code:The Contractor's License Law does not apply to an owner of
ten' +'t Q property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
s S himself or through his own employees,provided that such improve-
Ct
-
mentsarenotintendedoroffeted for sale.If.howeveq.the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
Sd or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that Ile did not build or im-
- Pr v�for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
Paw
1,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. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrector(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Commctoi s License law. TRACT NO. PARCEL NO.
IT lumcxempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
OwrgJ Dan ._ WATER SYSTEM 5.00
'�{.-\ O K' ACC.DATE ACC.FILE NO.
RS' P; A
OM ' OD:CLA RATION WATER TREATING EQUIP. 5.00
I hereby affirm oiCt I have a certificate ofemsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy themoffSec.3800,Lab.CA
Policy No. Company ,
Q ❑ Certified Copy lshereby furnished. - FIRE SPRINK ENERGY T-24
_z Z ❑ Certified copy is Filed with the city inspection division.
O Applicant MISC.- REFER TO ORD.
Y❑ I N❑ Y ❑ N❑
F- y PERMIT ISSUANCE- 10.00 FLOOD ZONE A.L.U.C..
LU CIiRTIIRCAI'li I ATIO TION PROM WORKERS'
W COMPEIiNSATION INSURANCE PLG.CONTR. UC.NO. PLG. y❑ N❑ Y❑ N❑
d ❑
This section need not TOTAL
he completed if the permit is Hof one
0 Z hundred dollars IS 100)or less.)
V O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F 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.
ED Date ApplicantALTER OR ADD TO MECH. 500 BUILDING SLIF�s{Z
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex . .
F Z emption,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 provisions or this Permit shall he deemed revoked. AIR HANDLING UNIT(TO 10PWC.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY - AIRHANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE ce d
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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
¢ information is correct. I agree to comply with all city and c.only
PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon'Ihe
BOILER-COMP,-IOver 100,000 BTU)SEE FEE BCH. MECHANICAL
above-mentioned property 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
nting of ^ n MECH.CONT. LIC.NO. MECH.
{�1 'Y TOTAL TOTAL �9I�
Signature of Applicant/Co moor o )am 000
OFFICE COPY