0531 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0531
ADDREi$
QQ 711 ` ,� ,� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S \ r ,P i '"-' a '" r G h:Y PLAN CHECK VALIDATION
It
E �.TV. 'r'ELECTRIC PERMIT( 11 'zFEE'y
CMITTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00
NAME t.�2
C 1 2 `�77 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS M
\J PHONE2 f O PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDoneSS ENO' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
W O o LICENSED CONTRACTORS DECLARATION CITY, OF, CUPLKIINU
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N<i (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
AUU 10 1981
o i Professions Coy a my license is in full f
z o N License ClassS lid Lic.Numb ❑ ❑ ❑
G L F D Date Contractor ac v
a it 2 I.BUILDINGiPERMIT,`
¢ ¢w OWNER-BUILDER DECLARATION ;�',cS.'N.✓:a{I NFORMATIONk':Fgf'l
'aocMISC.- REFER TO OR I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
E m� Code:Any city or county which requires a permit to construct,alter,
5 ¢ ¢ O Improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i - DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$a he is licensed pursuant to the provisions of the Contractor's License i.
E a Business anldrProfessions Codel or(hatwith s he ion 00zempt0therefromivision 3 fand QTY.-'.v.:7P.i .PLUMBING PERMIT } ' 'I FEEA
¢ the
D I^---' - '+ '���;y.- STORIES TYPE CONSTR.
¢ E the basis for the alleged exemption.Any violation ofSeclion 7031.5 ..t -'. `:i':,'... _ `y.:'
s ; .- byanyapplicant for a permit subjects the applicant toacivil 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 OCC.GROUP REB.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 i License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50,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-11NC.40UTLETS 4.00
Or improvement is sold within one year of completion,the Owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Osher
prove for purpose of sthe.l. INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the prstroct he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors t0 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.at apply
to contracts
owner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Cons forsuch projects Lwith acontmetor/s)licenxd pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law,
❑ I am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy the reyf e g any
Policy Nod i - any
Q ❑ Certified copy ii hereby fur fished. FIRE gPRINK ENERGY T24
Z 2 R-CeIII ca y is fi s t le .� inspec n division.
5i 1 MISC.- REFER TO ORD.
O Aplcan[ V❑ N❑ V ❑ N❑
F- y PERMIT ISSUANCE 6.0 FLOOD ZONE A.L.u.c.
CERTIFICATE OF EXEMPTION FROM Wf) KERS'
W COMPENSATION INSURANCE v .cONT s LIC.N PLG.
0. Z (This section need not be completed if the permit is for one A TOTA f Y❑ No Y C] N[]
hundred dollars IS 100)or less.) .1m
U O 1 certify that in the performance of the work for which this per. OTV. -f, EC ANICAL PERMIT v }. j FEE+SUMfcIAiiVr
FEE
0 F mit is issued,1 shall not employ any person in any manner or as to
OUl become subject to the Workers'Compensation Laws of California. �•` - ( '` BUILDING
y Date Applicant ALTER OR ADD TO MECH.t 4.00
} m NOTICE 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(TO 10p00C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 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 100,0008.T.U.) 4.00
Lenders NamAddress
Lenders e H EATING UNIT(OV ER 100,000 B.T.U.17.50
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 BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000BTU)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
mBy in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gr 'ng of hismiL MECH.CONT. LIC.NO. MECH.
TOTAL
S gn tot or APP!icon[/Conlraclar I=
OFFICE COPY