8473 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.— USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDRESS �1
H11,4,'Z -2 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL ' 4 7
NAMER'S PLAN CHECK VA LI ATION
AIE F ov,nP—D PHONE _2 CITY. ELECTRIC PERMIT FEE
PPR 2
CONTPACTOR'B
OUTLETS-SWITCHES-RECEP 10.00/1.00
2 �TIc No �L�� LIGHTING FIXTURES 10.00/1.00 at C°De�1°0
nooaEssT s �jnd"' PPLIANCES-RESIDENTIAL 4.00
v4tPANELS DATE OF APPLICATION
ORRCHOECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
L.C.NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALI ATION
ZIP ITEMP.METER OR POLE INS. 20.00 ,
noneEss Ts - (� MOTORS SEE FEE SCH. `�V J
L,Ct4l,E� SERVICE CHANGE '• I20.00
O a i
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE / 30.00
a z W I hereby affirm that 1 am licensed under provisions of Chapter 9 /�
N ¢ (commencing with Section 7000)of Division 3 of the f pBcu}s,i�nes�s�and BLDG. E ECTkUANCE PEG. MECH.
H 7 i Professions Code, d I s license is m full fort ndt
2 0`� — •Licen ass Num Y �'D. "DD'�
o Date Contractor
¢ y F '
rc a; w a OW ER-BUIL UIik UECLARA'fl B LDING PERMIT
a`K ;LL n I hereby affirm that I am exempt from the Contractor's License
MISC.— REFER TO ORD INFORMATION
H a. o a Law for the following reason.(Sec.703 1.5,Business and Professions VALUATION $/FT.
w-+ PERMIT ISSUANCE
Code:Any city or county which requires permit to construct,,also
u, ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a a o LL requires the applicant for such permit to file a signed statement that h TOTAL (, PERMIT TO
X $m he is licensed pursuant to the provisions of the Contractor's License
H 2 r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
�• g 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
fe the basisforthe alleged exemption.Any violation of Section7031.5 STORIES TYPE CONSTR,
by anyapplicam fora permitnAlf,ets the applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Bole compensation,will the work,and the structure Is not
imended 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
,properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
_ himself or through his own employees,provided that such improve.
Idents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Other
I
EI 1,as owner of the properly,am exclusively contracting with
licensed.contractors to construct the project(Sec. 7044, BusinessLAWN SPRINKLERS-1 INC 5 V.B. fi,00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not upply .
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fOr SaAch projects with a contractors)licensed pursuant to
the•Contructor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
rea❑nl am exempt under Sec. ,B.&P,C,for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5',00
ACC.GATE ACG,FILE NO. �
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-Z4
Z Z ❑ Certified copy is fled with the city inspection division. Y N V NE]
O Applicant— MISC.- REFER TO ORD.
CC y CERTIFICATE OIs EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.D.C.
1
W COMPENSATION INSURANCE PLG.CONTR. LICNoPLG. Y� NF] v � N�
° . . T-firths section need not be completed if the permit is for one 'TA
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not enspl a n Pers 'n any m r so as to
beta subject to c o no.t. s iforan.
U y , Datn� plicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOT E PPLICANT: If,a r mak g us .cr I to of Ex- '
♦— 2
Carrion,you should become subject Int ,Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 FEE
CONSTRUC'DON LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm [hal 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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I Certify that I have read this application and state Ila[the above VENTILATION FAN (SINGLE) 4,00 It
information is correct.1 agree to comply with all city and county BOILER-COMP13 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construct inn, and
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.
(We) agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
any \vay true agai st id City in consequence of the PERMIT ISSUANCE 10.00
gmn in f this pe I MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
Signature ofA r t/C nlretor D' e
OFFICE COPY
a _