4104 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4104
Aoo e,ss
U 21Y�2
[BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
NAMERAcroRs UTLETSG-SWITCHES-RECEP 5.00/1.00
LIC No. LIGHTINFIXTURES 5.00/1.00
ADDRESS APPLIANCES-PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE ,P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.06 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ASS MOTORS SEE FEE SCH.
S'
ADDRESS
SERVICE CHANGE 10.00 //p
o O O LICENSED CONTRACTORS DECLARATION
Q U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H< w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
mz Professions Code,and my license laid full forte and effect I ❑ ❑ ❑
z o w - License Class Lie.Number pT 1
9h wDate Contractor
a ( O _ C O /
¢ y s J / BUILDING PERMIT
¢ Ic w OWNER-BUILDER DECLARATION F RMATION
w S A H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
y VALUATION $/FT.
a. a.
Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city orcounly which requires a permit to construct.after, f�4(fa(�0
2 ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
i f D �
r z Law(Chapter 9(commencing with Section 7000)oivision 3 of the �,�t�UQ�'
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M r the basis for the alleged exemption.Any violation of Section 7031.5 �S/TORIES TYPE CONSTR.
i_: any applicant(lira permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA) q00 /J GR✓
of not more than five hundred dollars($500)): . ,
❑ I,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 net
Intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:T'he Contractor's License Law does not apply to an owner el'
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 s0.FT.FLOOR AREA TOTAL ACREAGE
m mend(re of intended
his own employees.Provided that such impmvc
meets are not...1, ,1, or offered employees,
or provided
thathowever,uthe building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder
wner GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that lie did not build or im- . . .
S IND CON PB Orber
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES
El 1:1❑ I,as owner of the property,am exclusively contracting with 1:1 El
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
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 contractods)licensed pursuant to
the Contractor's).,can. Ave. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl Iwn exem I, der Sec. ,BAP.C.for hills WATER HEATER W/VENT 4.00
earn,
Dat Q'4a Owner WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA19N DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a Certificate of consent to sel Ginsur0. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy the reof(Sec,3900,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division.
p: O Applicant MISC.- REFER TO ORD. Y ❑ NE] Y ❑ NNC]m PERMIT ISSUANCE 6.00
LU CIiRT'I PICf OF EXEMPTION FROM WORKERS' PERMIT ZONE A.L.UL.
W COCOMI'fiNSA'I'ION INSURANCE PLG.CONT LIC.NO. PLG.
CL Z( This section aced not he completed if the permit Is for one TOTAL Y❑ N� Y [:] N
Ej
hundred dollars IS 100)or less.)
U O I certify that in the performance of fit,work for which thriller. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is Stuart. I shall not employ any person in any manner so as to
U become subject ho the Workers'Compensation Laws of California.
O w Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING -S4j z
} Val NOTICE TO APPLICANT: If,after making this Certificate of Ex. .
? emptien,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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 5�
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. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application andstole that the above VENTI LATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating f0 building construction, :md BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SGH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs amt expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
graph nl'
is peep'. 1 MECH.CONT. LIC.NO. MECH.
oLu�a.. �ioa. OTAL TOTALS
Signature of Applicant/Contractor V Data (�-
OFFICE COPY