3507 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
P
BUILDING PROJECT lDENTI FICATION RMrYM RAPPLICATION & PERMIT
AOORENc ^5.O 7
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��! GO CCCR.ES� �'� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL _
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NAME�`c� tM/� /-/� /(�/.7.NE (� OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
�� DO 4) r MP,�iej&IIONE 1 9S 1/7i
NAAMCONRRacTORs UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES .5.00/1.00
ADDRESS TORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS - 5.00 DATE OF APPLICATION
oncnlTecT PLAN LHECK FEE- SIGNS - 6.00 P.C.NO.
ENGINEER
uc.No, SIGNS TRANS. 3.00
ADDRE08 SS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 -
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 �s ,
wooLICENSED CONTRACTORS DECLARATION
a v w I hereby affirm that Lam licensed under provisions of Chapter 9 A IrWUANCE DATE
,Ha Q Icommencing with Section 7000)of Division 3 of the Business and n ECT. PLG. MECH.
H 7- Professions Code,and my license is in full force and effect ❑ ❑
z o`�� License Class - o Number Z D
� Z Dale Contractor
¢ x rc a
OWNER DECLARATION BUILDING PERMIT
¢ w u - INFORMATION
e- 0 is H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD.
u O us Law for the fo1lowi0 reason.(Sec.1031.5,BotmeMand Professions *ALS/FT.
_w s PERMIT ISSUANCE 6.00 '
w > Code:Anycity or County which requires a permit to const
ELEC. (TQ'O
Q Improve,demolish,or repair any Structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELEC. /
to y 0¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Conlractoi s License
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Codel or that he is exempt therefrmn and CITY. PLUMBING PERMIT FEE
¢ F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicant too 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 DCC.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 SO.FT.FLOOR AREA TOTAL ACREAGE
imself or through his own employees,provided that such improve-
,m,are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
r improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING use
builder will have the burden of proving that fie did not build or im- RES wo CNG PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El O ❑ 11 ❑
❑ d as..net of the properly,he exclusively.7044,ing with
licensed contractors d 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 anowner of property who builds or improves thereon,and who iLAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200(t/8.00 TRACT NO. PARCEL NO.
❑ lam exy-mpt under a ,B.&I'.C.for this WATER HEATER W/VENT 4.00
reason �`I�' 6� idG TIC
- Date Owner ✓ WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'rION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent m self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z O ❑ Certified copy is filed with the city inspection division.Applicant MISC.- REFER TO ORD.
V N v N
~ a PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
� � CERTIFICATE OF EXEMPTION FROM WORKIiRS'
_ COMPENSATION INSURANCE• PLG.CONTE, LIC.NO. PLG.
CL O (This section need not he completed if the permit is lot one TOTAL V NE] V NEI
D Z hundred dollars($100)or less.)
U Q 1'Certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 W Dam Applicant BUILDING
pP ALTER OR ADD TO MECN. 4.00
} tail NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V - Such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE SD
I hereby affirm 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
Address
Lender's Address HEATI NG UN IT(OV ER 100,000 13.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all,city and county PLUMBING
ordinances and state laws relating to building construction, and 130ILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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
may in any way accrue against id City in consequence of the PERMIT ISSUANCE 3.00
gran `t MECN.CONT. LIC.N0. TOTAL �i
..((A •On�O z /?T? TOTAL TOTAL 0 �-
S�atureofAppll-mt/ on act I 7A
Cc, „LPJ✓1> 2lx"16 //g3 OFFICE COPY