2471 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICA710N
PERMIT NUMBER
� auaolNG
APPLICATION & PERMIT
_ 247.1
OORE55 _
SIJ BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
,NAry RACT Rs UTLETS-SW'TC
HES-RECEP 5.00/1.00
I c.N o� LIGHTING FIXTURES 5.00/1.00
-\
IFTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS �/
PH.NE79 3/7 PANELS 5.80 DATE OF APPLICATION
OR K SIGNS 6.88 PLAN CHECFEE P.C.NO.
ENGINEER LIC.NO, SIGNS TRANS. 3.00
ARC'Ess END' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 G, �2,-
00 LICENSED CONTRACTORS DECLARATION
u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m<n (commencing with Section 70001 ul Division 3 of the Business and - BLDG. ELECT. PLG, MECH.
H Professions Code nd in license is in full for ❑ ❑ ❑
z o H - License C ross L[a-Lic.Number •=T
0 w- w Date�/_n Q'7 Contractor '
r -
`¢ y f BUILDING PERMIT
c or w 4 OWNER-BUILDER D17CLARATION INFORMATION
m oaU MISC.- REFER TOORD
w g m I hereby affirm that 1 am exempt lions the Conlracmr'z License VALUATION $/FT.
FLLoa Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 q -/1
m w Code Any city or county which requires permit to construct,alter, ELEC.CONTR. LIC.NO. -2
u,u, Q o improve,demolish,or repair any structure,prior to its issuance,also ELEC. /
to requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m u- he is licensed pursoanl to the provisions of the Contrletor's License /140476'y Z
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe F'e<� S
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollar.(55001.):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 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, Rosiness and Profeeslons DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contract.,',License Law does not apply to an owner of
property who builds or improves Amnon,and who does such work FIXTURES-PER TRAP 4.00 so.Fr.FLOOR AREA TOTAL ACREAGE
meatsre througot h his own cared fors, le If.cd thus such int building
mmselfc throuhh is oro employee sale If. that s lite GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM.OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not hulld or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON Pe omv
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct file project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cod,:The Contractor'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 with a contractons)licensed pursuant m
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ l an,cxdmpt under Sce, .B.&I'.C.for this WATER HEATER W/VENT 4.00
reason
are Owner WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORKI?RS'COMPIiNSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure' ZONING
or a certificate of Workers'Cnmpennation Insurance.or a e,rtl6ed ENO.SITE NO.
copy thereof(Sec.3800,Lab.C.j,.�J
Policy No. Companyll��/'�N
1� Certified co is hereby furnished. FIRE SPRINK ENERGY T-24
h` Certifie y r the - 'I p 1' ''isi #m _CIS .- REFER TO ORD.
z0 Applicant f Y ❑ N❑ Y ❑ NE]
CC W CBRTIFICATI?OF EXEMPTION FROM WO001 PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
>_ COMPENSA'I ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d0 (This Section need not be completed if the permit is for one AL Y❑ N❑ Y TOT ❑ N❑
0 z hundred dohr"IS 100)or less.)
U O 1 certify that in the perfornance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not emplDy any person m any manner of as In
U become subject to the Workers'Conlpen.sut ion Laws of California. BUILDING If
L3vfa
W Days-Applicant ALTER OR ADD TO MECH. 4.00
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? en,oion,you should become subject to the Workers'Cuntpensulion APPLIANCE 4.00 PLAN CHECK r Q�
provisions of the Labor Code, you must forthwith comply with FEE �l1
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODOF.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
life performance of the work for which this permit is issued(Sec. MICROFILM
3007,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
L,ndcr's Namc HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I codify that l have read this application and star,that the above VENTI LATION F AN (SINGLE) 3.00
information is corned. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby uuthorire representatives of this city 10 "Iter upon the BOI LER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpuscs.
(We) agree to save, indemnify and keep hanNess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs oliJ expense which CONST.TAX
may in any way accrue ag' sI said City in consequence of the PERMIT ISSUANCE 3.00
gran:n ql this Dem I MECH.CONT. LIC.NO. MECH.
10_g TOTAL TOTAL (p SC 03
tgn utureof Apphicmf radar, Dade
OFFICE COPY