14420 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION " PEYMD NUMBER
BUILDING APPLICATION & PERMIT 144 20
+--
ADDRESS
P � -� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 'rr•• PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
,-
e,. � ,„D„E ZS.S.i�f�
CONTRACTORS '1- / V
NAME UTLETS-SWITCHES-RECEP 10.00/1.00 16)-
NAME
(/1•/15. 1&-(/. �'V&,NoLIGHTING FIXTURES 10.00/1.00
CONTRACTORS - A111 Z_ APPLIANCES-RESIDENTIAL 4.00
ADDREss /n= ''�rI /k.NE 6 (fl, i.y�CA /k.NE -7160 PANELS . 10.00 DATE OF APPLICATION ..
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLI SNrs MOTORS SEE FEE SCH. 9®
ADDRESS
SERVICE CHANGE 20.00 C(� •���OATE
o o LICENSED CONTRACTORS DECLARATION /I hereby Afinn that I am licensed an der provisions of Clupter 9 I lr1
N <Is (commencing with Section 7000)of Division 3 of the Business and r s -- BLD L'ECr. PLG. MECH.
H m z rof,waons Code, J m I ,,is in full force and effect A L. a\�I. ❑
z4 o m - :cense ClassLie.Number
r $ Datc_. I
Q y E J p
¢ ¢ w < OWNER-BUILDER DECLARATION G� BUILDING PERMIT
A o A U MISC:- \REFER TO ORD INFORMATION
NO 3 w 1 hereby affirm Thal 1 am exempt from the Contractor's r s License VALUATION S/FT.
H u_o j Law for the following reason.ISec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code!Any city or county which requires a permit W condo¢(,alleq
¢ ¢ G 0 improve,demolish,of repair any structure,prior to its issuanc0.also ELEL.CONTR. LIC.NO. ELEC.
- 0 , requires IIID appllcanl for such permit to IIIc a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License /
Hza
Law(Chapter 9(commenciog with Section 7000)ofl)ivision 3 ofthe 0 'V
i O Business and Prn fesaions Code)or that be is exempt thercframh and QTY. PLUMBING PERMIT FEE
a I-o the basis lis.the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate_ by any applicant lora permit subjecrothe applicant toa civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
.fact more than five hundred dollars(S500f):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered lar sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himselforotirlhhis ownemployees.fors, le.If,ed that however,
the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
40 meats um not, is sold or itfir,on for sale.If,however,the building
or improvcnmat is sold within one vicar of he didt ion,the own,
or
GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ire- RES IND CON PB CO.,
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I 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 ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contrathe Cons ctor'sor hcense Lwithacommcmrts)lianvd pursuantro SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's h projects
Law. _
❑ Ian(exempt coder Sec. ,BAP.C.tin this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00
ALL.DATE ACC FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificale of concent to sell:iasure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(Sec.3800,Lxb.C.).
Policy No. Company UNA
O ❑ Certified copy is hereby fumishcd. FIRE SPRINK ENERGY T-24
Z Z CcrliHc rpY i 2111 with the city inspection division.
Aplicant.. r"/17 _O -/,-- , MISC.- REFER TO ORD. Y❑ IN Y ❑ No
y f-IiRTIFICA'I'F.OP'Ii EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE - A.L.u.C. -J
> COMPI.NSATION NSURANCE: PLG.CONTE. LIC.NO. PLG,
CL (This section need not be completed if the permit is lin one TOTAL Y❑ N❑ v ❑ Is C]
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 ,droll not employ any Person in any uumier so us to
U become subject to the Workers Compensation Laws of Calilorniu.
U w Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING o
} y NOTICE TO APPLICANT: If,after making this Certificate of lix-
z_ emptiml,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 he dccned revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10J=C.F.M.) 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(Sec. MICROFILM
3097,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders No HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC d .
Leader's Address
I "Hil'y that l have read this app2c'ation and stab"Hu"the above VENTILATION FAN (SINGLE) 4.00
• information is correct.I agree to comply with all city and county BOILER-WMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slam laws relating to building construction, and
;* hereby xuthoriee representatives of this city In enter upon the BOILER-COMP(Ove.100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
.(We) agree to save, indemnify unit keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 !CONST.TAX
may in any way accrue against said City in consequence of the
mntin i, nnit MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL 9
ignatureof Applicant/ sractor. ate �!
OFFICE COPY