C 8402 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ABUILDINGoo.ESS APPLICATION & PERMIT A 0^
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'! .'-. ....... .•.. 3� PLAN CHECK VALIDATION
NAME L3 4-.: - t.`nla. ..Lr V//•�L�/•I "/
_ oars:..' e►Eenaew�irF'- ',...,, 7/
• PHONEji
NAMERAcroRS UTLETS
-SWITCHES-RECEP 10.00/1.00
9 LIGHTING FIXTURES 10.00/1.00
ADDRESS
AroR! APPLIANCES•RESIDENTIAL 4.00
ADDRESS y
QOO PNory 4%-4 PANELS 10.00 DATE OF APPLICATION
OR
RCNITECT PANELS (OVER 200 AMP) 20,00 PLAN CH CK EE P.c.N .
ENGINEE0.R
"C.No. SIGNS TRANS. 3.00
ADORE. Na' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zip EMP.METER OR POLE INS. 20.00
ADDRESS
A MOTORS SEE FEE SCH. /
RE5] %
(9 _ SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Or u
I hereby affirm that I am licensed under provisions Of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and B ,ELECT. PL EC
D z Professions Ca =rid 'cense is in full f
2 ort aB fe
o'� - License Class Contractor Number
9 - o Dete Con
N '�~ J
i W a OWNER-BUILDER DECLARATION 'r ,,lv, , :,:�{"• -
D a MISC.- REFER TO ORO
I hereby affirm that I am exempt from the Contractor's License �•VALUATION SIFT.
F w N Law for the following reason.ISec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Anycityorcounty which requires a permit to construct,miter,
z, c < p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UC.NO. ELEC. (/
w S.0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
w S he is licensed pursuant to the provisions of the Contractors License
H z in Law(Chapter 9(commencing with Section 7000)of Division 3 of the "' ,tA_I- Te'- • OL
< Business and Professions Code)or that he is exempt therefrom and fir- v
H the bear,for the alleged exemption.Any violation of Section 7031.5 -` :, Yx} - n a5'v STORIES TYPE CONSTR.
A. by any applicant for a permit subjects lheayplicant to a civil penalty ALTER•DRAIN&VENT-WATER IEA.) 5.00
of nor mart than five hundred dollars($500).1:
[11,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.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 to an owner of
property who builds or improves thereon,and who don such work FIXTURES-PER TRAP 5.00 aft FT,PLDOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments an not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-11NC.40UTLETS 8.00
or improvement is sold within one year of completion,the owner, GAS-EA.SYSTEM'•OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB olhar
❑ I,as owner of the property,am exclusively contracting with ❑ Cl ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-11 INC 5 V.B. 8.00 A55 RS PARCEL NO.
and Professions Code:The Contractor,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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.ZOOh/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
CI I am exempt under Sec. ,B.AP.C.for this
reason WATER HEATER WNENT 8.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING or a certificate of Workers'Compen Mtion Insurance,or a certified ENG.SITE NO.
r copy thereof(See.3800,Lab,C.l.
Policy No. Company
❑ Certified copy i,hereby fumishe // FIRE SPRINK ENERGY T-24
Z Z ❑ Cerufie py is de wit)1 e city ins titan dlrision.
O APPlicam MISC.• REFER TO ORD, Y ❑ N❑ v ❑ N❑
2 CERTIFICATE OF EXEMPTION FROM4 11ORKERS. PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, Y[]' N❑ Y❑ N❑
6. a IThis section need not be completed if the permit is for one IOTA
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of&A work for which this per- '-
LL F- mil is issued,I shall not employ any person in any manner so As to
O W become subject to the Worker,'Compenntlon Laws of Califomla. '
6 Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} f 11 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Worken'Compenvtion Of APPLIANCE 5.00 PLAN CHECK
provmms of the Labor Code, you must forthwith comply withFEE
U such provisions or this permit shall be deemed Invoked. AIR HANDLING UNIT(TO 10=C.F.IM 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)31GF.M.) 8.00 SEISMIC FEE
I 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
Lender's Name H EATI NG UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify the have read this application and stale that the above VENTILATION FAN ISI NGLE) 4,00
• information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 8.00
herebhereby enthoed ropresenuriins of this city es enter upon the BOILER-COMP(Over 10QODOBTUI SEE FEESCH. MECHANICAL
y
authorize
property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, costa and expenses which CONST.TAX
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE 10.00
grant of this permit. MECH.CONT. LIC.NO. MECH.
Tor TOTAL
X StUrature of Appejantx.ntrxclwerOW4Date
OFFICE COPY