3986 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.,- USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFI CATION PERMITNUMBER
•eoILOING . APPLICATION & PERMIT 3986
ADDRESS -
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
- - - - --�'- - PLAN CHECK VALIDATION
NAME ' OTY. ELECTRIC PERMIT FEE
4.
:) .PHONE _
NOAMERACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00 • -
LIC No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS APPLIANCES-RESIDENTIAL -4.00
- PHONE PANELS 5.00DATE OF APPLICATION '
ARRCHITECT SIGNS . 6.66 • PLAN CHECK FEE P.C.NO.
ENGINEER ,.
LIC.NO. SIGNS TRANS. 3.00ARCH,OR '
ADDRESS ENG SPECIAL CIRCUIT 5,06PER/M�IT VALIDATION ,
ZIP ITEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS - MOTORS •. SEE FEE SCH. .
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION -
¢i w I hereby affirm that 1 am licensed under provisions of Chapter 9 - ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
i Professions Code,and my license is in full force and effect B ELECT. PLG. MECH.
z o ar - License Class Lac.Number -
o: w Dace' Contractor - -
_ - d
¢_ a, w ¢. OWNER-BUILDER DECLARATION BUILDING PERMIT
w°` - - INFORMATION
3 y. I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD
u O A Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- st g PERMIT ISSUANCE 6.00
mw Code:Any city orcounty which requires a permit to constrocT alter,
ELEC.CONTR. - LIC.NO.
¢ ¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC. �a/,%V v _
e- wm¢ feQnlles the applicant for Such permit t0 file a Signed statement that TOTAL PER TO
he is licensed pursuant to the provisions of the Contractor's License W/yam/ 'J
riQ Law(Chapter 9(commencing with Section:7000)ofDivlslon 3 oftheA4
the
E 4 ° Business and Professions Code)or that hVV
e is exempt therefrom and CITY. PLUMBING PERMIT FEE u/ V
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penally - ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ I,as owne,..f 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 SQ PT.PCoaR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inmrove-
ments are not intended or offered for sale.If,however,the,building GAS-EA.SYSTEM-I Iso 4 OUTLETS 4.00 ,
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) ` UILDING USE
1.00 B
. builder will have the burden of proving that he did not build or im-
prove for purpose of sale J. INDUSTRIAL WASTE INTER. 2000 E IND CON EB Orbe+
❑ 1,as owner of the property,am exclusively contracting with . ❑ 13 0 ❑
licensed.contractors In construct the project(Sec. 7044,Business. LAWN SPRINKLERS- 1 INC 5 V.B. 5.00ABBEBsoRS PARCEL No.
and Professions Code:The Contractor's Licenae Law does not apply -
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-'OVER 5 (EA.) 1.00 -
contracts for such projects with a contraetons)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.'200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under San,-,B&P.C.I'or this.
reason WATER HEATER W/VENT . '• 4,00
Date �' WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
KERs'coMPEr ON DECLA
RIATION WATER TREATING EQUIP. 4.00 -
1 hereby affirm that I have a certificate of consent toself-insure,
or a certificate of Workers Compensation Insurance,or a,certified ZONING .ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). -
Policy No.__Company _
O ❑ Certified copy is hereby furnished. FIRE SPRINK, ENERGYT-24
Z,Z O Certified copy isFiledwith the city inspection division. O Q ❑ ❑
F OO.- REFER TO ORD. Y N Y, Applicant MISN
to CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 -FLo6DZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. - PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y ON[_ Y ❑ N❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of file work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
IL Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 4
>_ W NOTICE TO APPLICANT If,after mukingthis Certificate of Ex- '
F Z 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,ITO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.EM.) 5.00 SEISMIC FEE
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 H EATI NG UNIT(OV E R 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
oieinformation is correct. I agree to comply with all city and county _f PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
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 PERMIT ISSUANCE -- CONST.TAX
may in any way accrue against said City in consequence of the 3.00
grand ofill permit ' MECH.CONT. LIC.NO. ++ TOTAL
i nalureo , TOTAL
g pli ant Contract ate
OFFICE COPY