3376 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION BUILDING -ELECTRICAL-PLUPER N
BUILDING APPLICATION PLUMBING PERMIT 76
ADDRESS
7U G; ��� G
OWNER'S ' -' -'+ �T PLAN CHECK VALIDATION
NAME �Z�-t/pI` OTy, 'ELECTRIC PERMIT' -` -PEE '
CONTRACTOR
NAME
NgmE �¢LRd/ 0 00�/�5/b- UTLETS-SWITCHES-RECEP 5.00/1.00
/� /0 �/f/�if LIC.No. Z��� LIGHTING FIXTURES 5.00/1.00
CONTRACTORRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
- sec.NO. SIGNS TRANS. 3.00
ADDDDRESS ENc' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLIORESSser cMOTORS SEE FEE SCH. a
AO
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
c u si I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
mw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
on i Professions Cod nd I sYlicense is in full force anJ�ffgctL
' 0. - License Cla � � l Lic.Number
e m r w Date y�L/F�Conir
a y s '''n '40UILDING PERMITrIf l:,.S
s z w a OWNER-BUILDER DECLARATION "'M'M`W INFORMATION ,,;,.+d�'A
Wc A u MISC.- REFER TO ORD
; u.H I hereby affirm that 1 am exempt from the Contractor's Li ceme ATION $/FT.'
va 0A Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit to construct,alter,
a2 c 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. e
A e, requires the applicant for such permit to file a signed statement that TOTAL ^ PERMIT TO
A. w m he is licensed pursuant to the provisions of the Contractor's License
i Law(Chapter 9(commencing with Section 7000)of Division 3 of the % n r..r-s =✓QQQ�
r a Business and Professions Code)or that he is exempt therefrom al.d OTY. 1. '}; f PLUMBING PERMIT? +sFywr s }FE�!
X 1- $ the basis for the alleged exemption.Any violation of5ection 7031.5 Ll -- ?,t°F y,' i /sv„:,;'- °4_fits# .. ;�«$ Is..^ I TYPE CONSTR.
u ; -- by any applicam for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
Re-z' KC
of not more than five hundred dollars(S50(1.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.uNlrs
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 .S-G� N!}/ T
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 own employees,provided that such improve• GAS•EA.SYSTEM-1 INC.4OUTLETS 4.00 ments 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 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ El ❑ 0 C]
❑ d as owner of the construct
he exclusively, 7044,tBu with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-t INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profusions Code:The Contractors License Law does not apply
to antr owner of property who builds t r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 7.00
contracts actor's h projects with a contractor sl licensed pursuant
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam 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.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I 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(Sec.3800,Lab.C.). ff��
Policy No. Company
Q ❑�Certi Pied copy is hereby urmshed. FIRE SPRINK ENERGY T-N
Z Z L9'Cenifi c y rl with fhe•city inspection division. ❑ ❑ ❑ ❑
O Applicant -(-� �� �� MISC.- REFER TO ORD. y N y N
� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU ? COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG, Y N❑ Y N
C O (This section need not be completed if the permit is for one TOTAL
D Z hundred dollars IS 100)or len.) I );,._7„Sj "<k:a µ Ci,ptY,' y_" ";'x"
V Q 1 certifythat in the performance of the work for which this er t - s n..�-.A...•+.es.Ia.. F
FEE'.SUMMARY tth
P P ply, ,t - .MECHANICAL PERMIT Jy, " iFEE I `^?'+ 3.N_:..,...,...., -'.ba.� "
LL I- mil is issued,1 shell not employ any person in any manner so as to •r.,!p' .m �x7�.U..a�vCa� h✓✓K 1Mt..-,.<.3•iri
U become ssirye�,aso��the Workers'Co ens do a s California
w Date /- Applicant �rlv��,- W BUILDING LJ
Is. d ALTER OR ADD TO MECH. 4.00 T
} N NOTICE T APPLICANT: If,after making this Certificate Of Ex-
I... ? 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 10,000QF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10A0011F.M.) 5.00 SEISMIC FEE e3Z?
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which ink permit is issued(See. MICROFILM
3097,Cls.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree 10 comply with all city and county BOILER H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over,100,000 BTU)SEE FEE SCH. MECHANICAL
(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 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
grans ofthisyyermi x MECH.CONT. LIC.NO./ MECH
TOTAL +
cl� TOTAL
ksq- �d
? S��✓
Sign�o ApplicanllConlruci G,_
OFFICE COPY