5874 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALIj"gOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
all,qLp°F�,NG APPLICATION & PERMIT
7 "ZJQC,2,
aoC.CSS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5874
OWNER'S PLAN CHECK VALIDATION
N 1
$
Pnorvrp;[ 1667 OTY'. ELECTRIC PERMIT FEE
NAMERacrORs UTLETS•SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
ADDRESS Tona APPLIANCES-RESIDENTIAL 4.00
' PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Ua NO. SIGNS TRANS. 3.00
Arco.
oo Ess E 0. NO SPECIALCIRCUIT '5.00 PER
,Iy+IT VAL AT
nP EMP.METER OR POLE INS. 15.00
AODR ESS
APPLICANTS MOTORS SEE FEE SCH.
1.011
YT I
.
SERVICE CHANGE 10.00 '
O er i
FOO LICENSED CONTRACTORS DECLARATION
a i U 1 hereby affirm [],at I am licensed under provis mm.1'Chxpler 9 ISSUANCE DATE -
y¢ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PL MECH.
HOZ Professions Code,and my license is in full force and effect ❑ ❑ ❑
Z O 2License Class Lic.Number
o Dale C.Glractar
¢ Y F
a O n U OWNER-BUILDER DECLARATION BUILDING
EIONIT
X
g LL y I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
F LLD ¢ Law far the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
ELEC.CONTR. LIC.NO.
rt Q ¢ o improve,demolish,or repair any stR¢[ure,prior to its issuance,also ELEC.
n wD LL requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
m he is licensed pursuant to the provisions of the Contractor's License
r z i Law Whapler 9(commencing with Section 7000)nf Division 3 ofthe
i i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 1
tt
1- the basis for the alleged exemption.Any violation of$ection 7031.5 _ STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4,00
of not more than five hundred dollars(4500).):
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 Dec.GROUP RES.UNITS
[heir 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 Low does not apply to an ovenei of
property who builds or improves thereon,and who hat does such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself rilsare
not hrough
ownemployor Sale.If,ho ever,the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
meats arc not intended or offered for sale.If,however,the bowing
or improvement is e burden within one year of he did of oil owner- GAS-EA.SYSTEM•OVER 4(EA.) 1.00 BUILDING USE
builder will have the ahl.c. of proving that he did not build or im- RES IND CON PB Odua
pr .as Owose ol'sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
as owner of the properly,am exclusively contracting with
li •nod contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
an Professions Code:The Caninctor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.). 1.00
contracts for such projects will,a contmeta(s)licensed pursuant to
lkicTon tractors Lic' se low. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
um exempt under Sec. ,B.&P.C.for tlnis4-
I n WATER HEATER W/VENT 4.00
o
wncrUrn WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy thereof(Sec.3800,La b.0.), f
Policy No. Company
0 ❑ Certified cupY is hereby furnished.. FIRESPRINK ENERGY T24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ INC] Y ❑ No
CCN CERTIFICA1 E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG. O R/�(/ LIC.NO. PLc, ❑ C3 [30
EL 0 (This section need not be completed if the permit is for one /lb TOTAL Y N Y N
Z) Z hundrad dollars($100)or less,)
U O 1 certify that in the performance of the work for which this per. GTV. MECHANICAL PERMIT FEE FEE SUMMARY
man
LL F mil is issued,1 shall not employ any person in any ner so as to
0 0become subject to the Workers'Compensation Laws of California.
Dal y Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z coalition;you should become subject to the Workeri 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 AIR HANDLING UNIT(OVER 10,000GEM.) 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 ISec. MICROFILM
3097,Civ.0.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Leader's Name HEATING UNIT(OV 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 / r
infornotion is correct. 1 agree to comply with all city and'eoUnly - PLUMBING
40 ordinances and state laws relating to building construction, unit BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCM. MECHANICAL
above-mentioned property for inspection purposes.
(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 aceta, ai aid City in consequence of the
•r III, flhisp r 't MECH.CONT. . 'LIC.NO. MECH.
TOTAL /-�
TOTAL
i a reef,App icant o actor e
OFFICE COPY