15305 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATI ON PERMIT NUMBER
DILOING APPLICATION & PERMIT 1 O
ADDRESS
A P BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
'! 'NAME •✓ '�s•'�` PLAN CHECK VALIDATION_ O Irt
QTY. ELECTRIC PERMIT FEE
.ONE
NAMERAcrots UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.ry LIGHTING FIXTURES 10.00/1.00
ADDREss?ORs ��•x Mrf PPLIANCES-RESIDENTIAL 4.00
�• IOr- �� � HONE d[6 1' PANELS 10.00 DATE OF APPLICATION'S
ARCHITECT PLAN CHECK FEE P.C.NO.
DR - PANELS (OVER 200 AMP) 20.00 -. ,.
ENGINEER - '
LIC.NO. SIGNS TRANS. 3.00
ARG",OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00 ,`
ADDRESS rs -' MOTORS SEE FEE SCH. N'�^�IU�l1.-<?l�
APPLICA
SERVICE CHANGE 20.00
81101 I�,o
0 0 o LICENSED CONTRACTORS DECLARATION'
< Uw I I hereby afll To that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y< A (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. EC
F N i Professions Code and m license is in full(ores nd ( ❑ ❑ ❑
Oz Z m o Licwtse Class Lie.Number
H w Date Contractor
< Y s BUILDING PERMIT
¢ ¢w 1- OWNIi R-BUILDIiR DECLARATION
w ;A N I hereby affirm Ihut I ran exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
H u_0J " Law for the following reason.(Sac.7031.5,Business and Professions PERMIT ISSUANCE in on
VgWATION $/FT.
Code:Any city or counly which requirese ren niit to construct,alter.
¢ Q Q Improve,demolish,or repair any Shnclnre,prior In IIS issuance,also ELEC.CONTR. LIC.N0. ELEC.
ta D¢ requires the applicant for such permit to file a Signed statement that TOTAL
A w m he is licensed pursuant to the provisions of the Contractor's License PER RMiT T
Law(Chapter 9(commencing with Section 7000)ofDividam 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom andLUMBING PERMIT FEE
¢I-othe basis fur the alleged exemption.Any violation of$ection 7031.$ QTY. PSTORIE TYPE CONSTR.
iR at� by any applicant fora permit subjects lheapplicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more(Iran five hundred Dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 Oce.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 IG an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
r himself or through his own employees,provided that Such impmve-
mentsarenot'intended proffered for Sale.11,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner.
( builder will have the burden of proving that he did not build or im GAS•EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 Ellicensed contractors to Co IRRICt the project(Sec:7044,Business LAWN SPRINKLER$-1 INC 5 00 ED ASSESSORS[_-1ARCEL N0.
and Professions Code: the Contractor's License Law does not apply V.B.. .
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 -
theContractor'sLicenselaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCELNO.
❑ Iain exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT .. 6.00
reason
Owner Date WATER SYSTEM - - 5.00 ACC.DATE ACC.FILE NO.
WORKHRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING, ENG.SITE NO.
copy it 0I. ryay)� ,�
Policy mlipdtry!1.`n pr .
O O CC�citified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z•Z A la�(:ertifie �qpX is 1.1 i'ed IJI he c' mi%i.. division.
-II O'VyUI sy �t �` MISC.- REFER TO ORD,
~ ria PERMIT ISSUANCE 10,00
- CERTIFICATE OF BXF-MPITON FROM WOR ERS' FLOOD ZONE A.L.u.C.
LU 0 COMPHNSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
(This section need not be completed if the permit is for one TOTAL V❑ 'N❑ Y ❑ N❑
Z hundred dollars lS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY -
IL F mit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Cc m Dorset ion Laws of California.
Q. Dam Applicant ALTER OR ADD TO MECH. 5.00 - BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of F:x-
? '.. entption,you should become subject to the Workers'Cmnpensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lorlhwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.
the perf Rrnhi
ance of the work let wch this permit is issued(Sec. MICROFILM
s 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.)
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this appIke.bOn aild State that the above VENTILATION FAN (SINGLE) 4,00
information is correct. 1 agree to comply'4tr all try mal county g01LER•COMPIS H.P.Df 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives inspection
city es enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL (5 1.-l./
herebymaut orizned property torinspofth i purposes. n
(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 .1g-6B. a 00 CONST.TAX
may in any way acce against said City in consequence of the
ran g this Dern'ruM CH.CONT. LIC.NO. MECH.
j pp Y' ��\1 TOTALa_:= TOTAL yJf
Si t e fA licent/Conlmctor Ie U
FFICE COPY