8537 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUT LOI NG PROJECT 1 DENTI FICATIO PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AD ss n i / {7 &) BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8537
IiY1NER'S U L (/(-,/� ,-u� PLAN CHECK VALIDATION
Adhisy it G_ L ()N Z PHOrvEYS16 ^OICITY. ELECTRIC PERMIT FEE
NAMERADTDRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECKFEE P.C.NO.
OR
ENGINEER
' LIC.No. SIGNS TRANS. 3.00
AARCIT OR DDRESS ErvG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER O S. 20.00
APPLICANT'S MOTORSSEE FEE SCH. S�
ADDRESS
SERVICE C E - 20.00
,02 LICENSED CON"TRACTORS DECLARATION TEMP.POLE 30.00
<v D I hereby affirm that 1 am licensed under Provisions of Chapter 9 LMY Ot Cupartino ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Fi Professions Code,and my license is in full force and effect. El El
o License Class Lie.Number
o m r w Datc Contractor
y F a BUILDING PERMIT
¢ Ic
4 OWNER-BUILDER DECLARATION'T'ION
oA - MISC.- REFER TO ORD INFO MATT
aa ;a w I hereby alfrm that I am exempt from lire Contractor's License vt V IO Y/FT.
LL o j Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE -TTM
;;
Code:Any city or county which requires a permit to construct,alter,
Ia Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
- DLL requires the applicant for such permit to f ile a signed statement that TOTAL 6, � I ^
u M
w $ he is licensed pursuant to the Provisions of the Contractor's License
�9V / C���R iG
FiQ
Law w(Clapler9(commencing with Section 7000)of Division 3 of the V� G
Business and Professions Code)or that he is exempt therefrom and OTY, PLUMBING PERMIT FEE
H 0 the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
d ;� by any applicant for a permit subjects the applicrosi ton civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500)):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Scc. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
mems a re not intended or offered for Sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6:00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did no[build or im-
ProveJet EmpOaeOfsale.)' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB 011H.,O nt
1,as owner of the property,ran esdusivriy coracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner rf property who builds or improves thereon.and who LAWN SPRINKLERS- 5 IEA.) 1.00
contracts for such projects with a contractoAs)licensed pumiant to SEWER-SANIT T RM Oft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ exempt unJer B.&P.C.for this yyATER HEAT /V 6.00
xroaso a
Owne D; WATER SYSTE 5.00 ACC.DATE ACC.FILE No.
ORKE:RS'COMPF;NSAFI ECLARATIO WATER TR LEA
O 5.00
1 by affirm that I have a certif to of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy(hereuf(Sce.3800,Lah.C.).
Policy No. Company
Q ❑ Certified copy shereby lurtushed. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ No Y ❑ N❑
cc y CERI'1171CATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE: PLG.CONTR, LIC.NO. PLG.
(L 0 (This section need not be completed if the Permit is for one TOTAL/ Y❑ N Y ❑ N❑
D Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work I'or which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.1 shall not employ any person in any manner sn as to
U become subject In the Workers'Compensation Laws of California.
UJ
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT': IL after making this Certificate of Ex-
F.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.RM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the
perrf.reraace of the work for which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.) 8.00 MICROFILM
309CwLender's Ndme
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC _
6
I certify that I have read this application and state Ilial the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING 0
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
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 CONST.TAX
y m any way tic Tu a Const said City in Consequence of the PERMIT ISSUANCE 10.00
gr ling of this pen MECH.CONT. LIC.NO. MECH. T
TOTAL TOTAL J V
O
at-urrill'Applic nt/Contractor 04 114
OFFICE COPY