9445 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
I DENTI FvICATION
PERMIT NUMBER UMBER
APPLICATION & PERMITBULINS Gp7 ( BUIL
tam, DING - ELECTRICAL-PLUMBING-MECHANICAL 944
L/ O MER PLAN CHECK VALIDATION
,( CITY. ELECTRIC PERMIT FEE
ONE(
T I NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
COD NTRA RRAcroR's IA
APPLIANCES-RESIDENTL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT _ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE .C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 /1
ADDRESS is MOTORS SEE FEE SCH.
AGGRESS -
SERVICE CHANGE 20.00
p L i
�o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 O ��p f
a i w I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Bminoss and ISSUANCE DATE
�z Professions Code,and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
0 n o License ClassLic.Number
-
0 w J Date Contractor _
a m s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION '
A a a u INFORMATION
w ;LL u 1 hereby affirm that I am exempt from the Contractor's Licenu MISC.- flEFER TO ORD
u O j Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
H _ PERMIT ISSUANCE 10.00
� w0 Code:Any city orcounty which requires aperonit to construct,alter, '-
Se ¢ ¢ Improve,demolish.or repair any simchure,prior to its Issuance,am ELEC.CONTR. LIC.NO. ELEC.
wD ¢ requires the appllciou for such permit t0 I11e a signed statement that - TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Conirnclor's License _ /
Law(Chapter 9 loommencing with Section 7000)of Division 3 ofthe �LB b,�
4 o Business and Professions Code)or that be is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; by any applicant for a pemsit subjects lire applicant to a civil penally
of ,of mom man five hundred dollars[$5001.1: ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
'intended or offered for sale (Sec. 7044. Business and Profesgons DRAINS-FLOOR,ROOF,AREAS COND. 5.00
Code:The Contractor's LicenseLawdo¢not apply to an owner of
property who builds Or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself m through his own employers.Provided that such improve-
ormerits improvnot ement is sold or within
onfemd )curscale.oIf,howevec the the owner- GAS-$).SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove 1,ars owner of sale.[. INDUSTRIAL WASTE INTER. 3000 RES INDQ -CON PB 1lir
❑ d as owner of the property,he exclusively. 7044,E lug with �.I �. ❑
licensed contractorssiohas In construct the project La 7044,Rosiness LAWN SPRINKLERS-1 INC 5 V. 6:00 ASSESSORS PARCEL No.
and Professions Code:The Contractor's License Law docs not apply A.
Toan trowner ofproperlywho buildstr improve thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 nG
contracts fior eld License
ts Lwithaconlractorlsl licensed purulam to SEWER-SANITARY-STORME s�a!1!�ft7111 )
' the COntracloi s Licenu Law. !-may TRACT NO. PARCEL NO.
O 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT _6.00
reason
Owne Doc WATER SYSTEM O 5.00 ACC.DATE ACL.FILE NO.
WORKIiRS'COMPILNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hceby alfirn That I have.0 certificate of consent In self-insure. ZONING ENG.SITE NO.
or u certificate of Workers'Compensation Insurance,or a certified zz
copy thereof(Sec.3800,Iah.C.).
Policy No. Company
O ❑ Cer-ifed copy is hereby furnished.
Z Z ❑ Cerifird Copy is Filed with the city inspeclion division FIRE SPR INK ENERGY T-2a
O Applicant MISC.- REF ER TO ORD. Y� N❑ YQ N�
N CERTIFICATE.OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 7 COMPENSATION INSURANCE PLO.CONTR. LIC.NO.. . PLG.
CL CI I' rhis section need not he completed if the permit is for one TOTAL Y❑ N[J Y❑ NF
hundred dollars 1S 100)or less.)
U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U our is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation laws of Califomia.
It Data Applicant BUILDING
>_ 0 NOl'ICE TO APPLICANT: If,after making this Certificate of Fix- ALTER OR ADD TO MECH. 5.00
F 2
caption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor-Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be Oriented revoked. AIR HANDLING UNIT(TO 10)CODC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.NL) 6.00 SEISMIC FEE
1 hereby aMram that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
lire ped conimec of the work for whit[, This pemrit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(O V ER 100,000 B.T.0-)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that The above VENTILATION FAN (SINGLE) 4.00 �-
information is correct. I agree to comply Willi all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CONP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILEfl-COMP (Oxer 100,000 BTU)SEE FEE SCH. MECHANICAL
have-mentioned proPetly for inspection purposes.
(We) agree To Cave, 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 aceme against said City in consequence of the
grant i Of(hu rmi{ /I '/ MECH.CONT. LIC.NO. MECH.-
i// -,7d TOTAL TOTAL
Nilbralum of Applicant/Commetor Date r1� ,
OFFICE COPY