14138 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• PERMIT NUMBER
BL ILDI NG PROJECT IDENTIFICATION APPLICATION & PERMIT
ABUILDING 1413 8
OOR ESS
n `�.-7 ��.T�� � BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S Cl ,L(tp,� PLAN CHECK VALIDATION
"AME `ham DTV. ELECTRIC PERMIT FEE
Y. ��sn NEz
r / CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
b eo. IC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S 4��) PPLIANCES-RESIDENTIAL 4.00
TZPHON PANELS 10,00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20.00 isLANCHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OH ENG. 5,00 PERMIT VALI DATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. /9
ADDRESS /K`
SERVICE CHANGE 20.00
o rt i // (Q
Foo LICENSED CONTRACTORS DECLARATION 1
a U U I hereby elf int,that I am licensed under provisions of Chapter 9 ///,SSU NLE DATE
y z w (commencing with Section 7000)of Division 3 of the Business and G. ELECT. PLG. MECH.
D z Professions Code,and my license is in full force and fleet ❑ ❑
z o {2 - Licenu Clas Lia Number
o o�% Dat Contra-tor
a` Y f� BUILDING PERMIT
5 w OWNER.BU1LD.R DECLARATION INFORMATION
X 3 LL w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
e o 4: Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
LNto Code:Any city or county which requires a permit to construct,alter,
re improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
La m he is licensed pursumrt I.the provisions of the Contractor's License
Hii
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
sic the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
i ; m by any applicant a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more titan five hundred dollars(45000:
❑ I,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 (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 5,00 50.FT.FLOOR AREA TOTAL ACREAGE
bimsellor through his own employees,provided that such improve- GAS-EA.SYSTEM-I1NC.4OUTLETS 6.00 .
.cuts are not intended or offered for Sale.If,however,the building
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 not build or im- RES IND CON Pe oma
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct tie project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO.
❑ lam exempt under Sec...B&P.C.for tins WATER HEATER W/VENT • ' 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
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 thereof(See.3800,Lab.C. lA n�F l•dL
Policy No. Compenl
10 ❑ Certified Copy is hereby famished FIRE SPRINK ENERGY T 24
Z Z �'Certified copy is with 'nspection division. MISC.- REFER TO ORD. V N❑ V � N❑
F O� APPIiCan�
CCrn CERI'IFICA'I'G 017 I:XEMPI'ION 17ROM WORKERS' PERMIT ISSUANCE 10.00 Q FtooO ZorvE A.L.u.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. 7 n OO
CL O TOTAL 1{J V F] NE] V N
IT'his section need not be completed if the permit is for one
Z hundreddollas(S1000orless.)
U O 1 certify that in the performance of the work for which this per- TY.DMECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner So as to
Ow becoric,Holettothe Workcrs'Compcmation Laws ol'California' BUILDING
OIL Date Applicant ALTER OR ADD TO MECH. 5.00
} US NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensztiun 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 140WGEM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea MICROFILM
3097,CiYC.). ) HEATING UNIT(TO 100,000 B.T.U.) 8,00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.19.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 D
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.) 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
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this per ni r MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ISg fAppl t/C t N t
OFFICE COPY