6305 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- - -
BUILDING PROJECT 1DENT[FICATION PERMIT NUMBER
APPLICATION & PERMIT [/j��
•• aD'ORESG 6 3 0 5
noDREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
RNERs N/GGGaL84ST
OWNER'S � - PLAN CHECK VALIDATION
NAME
`/��,/,��J. �/ OT E L ECTR 11 C.P�,yE$R�M IT FEE
VMONEVf`.J -l71 / ...lM,/':T F /�V.�+-.�C 4•`d7 .
�-�
NAME OUTLETS UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00 -
IrGWNTRACTORs
$
-RESIDENTIAL 4.00
ADREAPPLIANCES
�OQm PHONq.VIoM
PANELS - 5.00 DATE OF APPLICATION
ARRNO
.0
SIGNS 6.00 PLAN CHECK FEE P.C..C.N .
ENGINEER LIC.No. � SIGNS TRANS. 3.00
ARCH.OR ENG SPECIAL CIRCUIT $,0O - PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE 1 5.00
APPLICANTS - - MOTORS MAY . SEE FEE SCH.
ADDRESSSwww
SERVICE CHANGE .00
F a o LICENSED CONTRACTORS DECLARATION
a is w I hereby affirm that I am licensed under provisions of Chapter 9 city ISSUANCE DATE
H< m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w z Professions Co nd my licenu is in full, • .
Z. G License CI Lic.Number ❑ ❑
9 A w Dale-� Contractor
-J
¢ m s ?BUILDING°r IM1T
a Q a Q OWNER-BUILDER DECLARATION - ':'` INFORMATIO'N
wDaD MISC.- REFER TO ORD ,`' I'-' '
g LL N I hereby affirm(hat I am exempt from the Contractor's License VALUATION SIFT.
� uN ¢ Law for the followiagreason.(Sec.7031.5.Business and Professions PERMIT-ISSUANCE 6.00, (�' -
Code:Any city or counly which requires a permit to construct,alter,
ELEC.CONTR. LIC.NO.
¢ a ¢ 0 Improve,lela,lish,Or repair any structure,prior to Its issuance,also ELEC. .x
A w m LL he is licensed
the dp pursuant
for such palmi to fele a sinned actor's i Ina( TOTAL/ PERMIT TO FL,eC
he Is licensed pursuant en the with Section
of the Contractor's License n OP'o��n G
rza Buw(Chand Professions
is 00)of exempt therefron 3 om and
- s • /-
4 c Business and Professions Code)or that he is exempt therefrom and OT•Y.•...` 'yPLUMBING PERMIT FEEp.�.
M I- rhe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3� by any applicant for a permit subjects the applicant,to a civil penalty gLTER-DRAIN -WATER (EA.) 4.00
of not mom than five hundred dollars(S500)J:
❑ I,as owner of Ihb property,or my employees with wages as BACKFLOW 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 - '
Properly who builds or improves Ihereou,and who does such work FIXTURES-PERT RAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered 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-
builder will have the burden of proving that lie .e did.no(build or im- - - RES IND CON PB Omer
prove for purpose of sale.). I NDUSTR I A L W ASTE INTER. 20.00
❑ I,as owner of the properly,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 properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractorls)licensed pursuant to
the Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under SEC.-,B.&P.C.for this WATER-HEATER W/VENT 4.00 -
reason
Owner Dale WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSAI'ION DECLARATION WATER TREATING E 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'CLab.ompensation Insumnce,.or a certified
copy thereof(Sec.3800, p.n;C P6604e 0014 r
Policy N rt C hmpany
❑ Certified yis herehy lurnisl _ a ty of FIRE SPRINK ENERGY T-24
z ❑ Cert" d led w y IRS tion division. MISC.- gwioORD.
Applicant Y❑ N❑ Y❑ N❑
W CERTIFICATE OF[EXEMPTION FRO W KERS' PERMIT ISSUANCE 6.00 FLOOD 2oNE - A.L.U.C.
. LL > COMP17NSATION INSURA 4 E PLG.CONTR., ... LIC.NO. PLG.
CL o (This section need not be completed if the permit is for One TOTAL /4 -� Y❑ N Y ❑ NO
7) Z hundred dollars(S 100)or less.) . • .•;b
U O 1 certify(hal in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY, • Afi
LL F- our is issued, I shall not employ any person in any manner so as to - -
U became subject to the Worken'Compensation Laws of California.
0w Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} tad NO ricE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked.- AIR HANDLING UNIT(TO10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOJX0C.F.M.) 5.00 SEISMIC FEE
I hereby affirm (hat 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 S.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC '41
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00 -
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER•COMP(3 H.P.of 100,0008.T.U.1 4.00
herehy 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
may in en accrue against Ci( in onuquence of the PERMIT ISSUANCE 3.00
g crinin. MECH.CONT. LIC.NO. MECH.
S TOTAL TOTAL
Signature if Applicant/Contractor ate
OFFICECOPY