2738 (2) �. . APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
PE IT
BUI LDI NG PROJECT I DENTI FICATI ON
BUILDING APPLICATION & PERMIT
ADDREa
;, '. t� UILDING - ELECTRICAL-PLUMBING-MECHANICAL
o
OWNER'S t�� -7 PLAN CHECK VALIDATION
"A J •Y CITY. ELECTRIC PERMIT FEE
0
colarnacTORs� f UTLETS-SWITCHES-RECEP 5.00/1.00 ,
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS N - PPLIANCES-RESIDENTIAL 4.00
�44Q� vNDrvE .57 PANELS 5.00 DATE OF'APPLI CATION
ECT Y� SIGNS 6.00 PLANCHECKFEE P.C.NO.
ENGINEER
uc,Na.- SIGNS TRANS. 3.00 -
ADDRESS END SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 15:00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
AlvSERVICE CHANGE 10.00
o 2 LICENSED CONTRACTORS DECLARATION (/ p Alf-
on
w I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
(commencingwithSection 7000)of Division 3mf Ibe Business and
¢ c BLDG. ELECT:"' PLG. MECH.
D°' Professions Co and my license is in fulbfa a d (fact. ❑ ❑ ❑
2 0 Licenu Cla Lie Numb
`?m r w Date Conlractnr
a se s dBUILDING PERMIT
rc a ¢ OWNER-BUILDER IIECLARA'DON -
c s u INFORMATION
X ; u_u I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F ISD ¢ Law for the following reason.(Sec.7031.5,Busmessand Professions PERMIT ISSUANCE 6.00 VALUATION SIFT.
Code:Any city or county which requiresa permit to construct,alter,
a 4, < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u S e , requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m L.
he is licensed pursuant to the provisions of the Contractors License
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 offle Cil
f 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
IE f$ the basis for the alleged exemption.Any violation of8ection 7031.5 STORIES TYPE CONSTR.
i ; by any applicant for a permit subjects the applicant Lou civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more thun five hundred dollars(8500).):
❑ 1,as owner of 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.FT,FLOOR AREA TOTAL ACREAGE
himself through his own employees,Provided that such imI!rove- .
mems are
not intended or offend for sale.If however,the,,.doing GAS-EA.SYSTEM-1INC.4OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM. 4 IEA.) 7.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . RES MD CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as,owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensed contractors to 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 not apply
ID an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with o conlractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200108.00 TRACT NO, PARCEL NO.
❑ I um exempt under Sec. - ,BAPC.for this WATER HEATER W/VENT 4.00
reason
Date Owner � WATER SYSTEM 4.00 A.CC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate"I to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. - Company
O ❑ Certified copy is hereby famished FIRE SPRINK ENERGY T24
Z 2 ❑ py is Filed with city insp vIi s divislon'is Filed with city insp vIi t division. MISC.- REFER TO ORD.
O APPlicant Y❑ N❑ Y ❑ N❑
~ m PERMIT ISSUANCE 6,00
LU ClCIiRTIFICA" NSATIPTION FROM WORKEI TOTAL FLOOD ZONE
vA.L❑.U.C.N❑
W 1 C :N SATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL 0 (This section need nal be completed if the permit is for one
hundred dollars($100)0oless.)
U O 1 certify that in the performance of Ihe.wark for which this Per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. '
0. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
>_ W NOTICE TO APPLICANT: If,after making this Certificate of lix
2 eruption,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 10,000C.F.M.) 3.00
CONSTRUCTION LENDIriG AGENCY AIR HANDLING UNIT(OVER 10,000C.F.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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 C� MICROFILM
3097,Civ.C.).
Lender's Name' HEATING UNIT IOV ER 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
information n correct I agree to comply with all city and county . PLUMBING -
ordinances and state laws relating to ly with all city an ion, and BOILER-COMP( 00,000 B.T.U.) 4.00
hereby entioed •roperly tarriespec this city IO enter upon the BOILER-COMP (Dear 100,000 BTU)SEE FEE SCH. MECHANICAL t7 0
above-mentioned Property for inspection purposes. ,/
(We) agree to save, indemnify and keep harmless the City of MISC.- L $FER TO ORD.
Cupertino against liabilities,judgmems, costs and expenses which PERMIT I CE 3.00 � CONST.TAX
may in any way accrue against 'id City in consequence of tlm `.
'0 of this permit MECH.CPNT. L NO. MECH.
/,�, City ofilpertino TOTAL c o TOTAL
S na are o1' pl' ant/Conlrlcfor ua I ✓
OFFICE COPY