5966 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMITNUMBER
BUILDING APPLICATION &,PERMIT
' AooREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL IJ
L I D L wad
mZNER'S -- PLAN CHECK VALIDATION
NAME
TV. ELECTRIC PERMIT FEE
DNBQ$-- ! e3s
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
ADDRESS
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 '
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' Lm.NO. SIGNS TRANS. - 3.00
ADDRESS ENO. SPECIAL CIRCUIT 6-00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 �1
Ars MOTORS SEE FEE SCH.
ADDRESS DOREss ,
SERVICE CHANGE 10.00
'w tl o LICENSED CONTRACTORS DECLARATION
a u I hereby affirm that I am licensed under provisions of Chapter 9 r ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
H m 2 Professions Code,and my license is in full fame and effect. OLDC. ELECT. PLG. MECH.
o i L o License Class Lic.Number ❑ 0
F
r m j Date Contractor q(1p t1
se¢ a OWNER-BUILDER DECLARATION SEP 4 , . Ir70'1 BUILDING PERMIT
S,
a u _ INFORMATION
E:
B. I hereby affirm that 1 am exempt from the Contractor's License MISC.- - REFER TO ORD
G VALUATION E/FT.
r LL o a Law for the following reason.(Sec.7031,5;Business tied Professions PERMIT ISSUANCGRY Of CUPertiII0 6,00
r.
Code:Any city or county which requiresa Permit to conslruct.aller,
rt2<O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTP. LIC.NO. ELEC.
a KO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe EL�G'T
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE f -
¢ H $ the basis for the alleged exemption.Any violation Of Section 7031.5 - STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant tea civil penalty ALTER-DRAIN -WATER IEA.) 4,00
of not more than five hundred deltars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW 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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his ownwnployees,provided that such improve-.
meets are net intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or 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 he did not build or int- RES IND CON PB Othar
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,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 riot apply
to an owner of property.who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA,) 1.00
contracts lot such projects with a contraclons)licensed pursuant to
the Contractor',License Law. -' SEWER-SANITARY-STORM_EA.200ft/8.00 TRACT NO. PARCEL NO,
/
re'❑, 1 t cxet r5cc. ,BAKC.for this WATER HEATER W/VENT 4.00 v
x
Owne Uat - WATER SYSTEM 4.00 . ACC.DATE ACC.FILE NO.
WORK S'COMPIiNSA ION DIiCh ATION WATER TREATING EQUIP. - 4.00
I hereby affirm that 1 have a certificate ofconsent to self-insure. ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec,3800,Lah.C.).'
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
zz ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ Nt[o] y ❑ No
H CERTIFICATI:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONA.L.U.C.
W > COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG.
IL O (This section need not be completed if the permit is for one TOTAL Y❑ NN❑
0 Z hundred dollars IS 100)or less.)
0 O I certify that in the performance of the work for which this per, DTVMECHANICAL PERMIT FEE FEE SUMMARY
LL H 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 i Datc ApplicantALTER OR ADO TO MECH. 4.00 BUILDING
>- rn NOTICE 1'0 APPLICANT: II',after making this Certificate of E..
Z emption,you should become subject to the Workers'Compensmien 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(TO 10DWC.F.M0 3.00
(
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOGEM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for ,EXHAUST HOOD(WITH DUCT) 2.00
theperformance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000'B.T.U.1 4.00 MICROFILM
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address � .
I certify that 1 have read this application and stale 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorite representatives of this city to enter upon the BOILER-COMP(Over iao,ODOBTUI 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 any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 _
ting of t is P MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of pplicantjContmctor Date
OFFICE COPY
r