1527 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
101 BUILDING PROJECT IDENTIZATION
aDILDING APPLICATION & PERMIT
ADDRESS K RTBUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1
42 5 Z 7
NAME R p SSI -_ 1- _ PLAN CHECK VALIDATION
• '7 ILI L�J ( �-J�"r S�J�'3� ���. - ELECTRIC PERMIT l.'FE�E^
NOrvE
CONTRACTOR'S
NAME f OUTLETS-SWITCHES-RECEP 5.00/1.00
(V(- �-4`-51 LICNO. 34'00 � LIGHTING FIXTURES 5.00/1.00
CONTRACTOR AqEiPPLIANCES-RESIDENTIAL 4,00
ADo Ess_lr ��
W 5NN~ 04<5
PHONE 37k-10
1 PANELS 5.00 DATE OF APPLICATION
AARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
O
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
1 ZIP EMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
DDRESS ss
AooR
SERVICE CHANGE 10.00 _ / /
w o o LICENSED CONTRACTORS DECLARATION - -/"J /
a i I hereby affum that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
ul-i a a BLDG. ELECT. PLG. MECH.
D O 2 Professions Code I.It my license is in full to a nddeffect, ❑ ❑ ❑
OZo 12 License Class _ Lic.Number l O 1 1
q n=w Dale Contractor
a az s BUILDING PERMIT.
a OWNER-BUILDER DECLARATION
a o a u INFORMATION
I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u O a Law far the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
_ g PERMIT ISSUANCE 6.00
Code:Any city or county which requirese permit toconsua c alter, I Od
aa ¢ ¢ G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A wDLL requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
r2i Law(Chapter 9(commencing with Section 7000)of Division 3 of the /7
E 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT: FEE.-
H $ the basis for the alleged exemption.Any violation of Section 7031.5 RIES TYPE CONSTR.
i ; „ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mom than five hundred dollars(5500).):
❑ Las 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 not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner Of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ FT,FLOOR AREA TOTALACREACE
himself re through his own employees,provided that such improve-
ments are not intended or employee sale.Tided that such
he building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 build or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. RES IND CON Pe Other
❑ I,as owner of the property,am exclusively contracting with 20.00 ❑ ❑ C1 ❑ ❑
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 contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B4P,C.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORKF-RS'COMPEiNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Com eny4{. Insurance,or a certified ZONING ENG.SITE NO.
copy Cher (;qj,$o jg01�6. A
otND. 1'o an ST A'CC FARM
0 fJ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T3<
Z 0 ❑ Certifyed co)�j�is led Ilth the city inspection division. MISC.- REFER TO ORD. Y [3 N� Y C] N[]
O Applicant�^
LA PERMIT ISSUANCE 6.00
LU CERTIFICATE COMPENSATION
INSURAN WORKERS' FLOOD zorvE aL.u.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. pLG.
0- 0 (This section need not be completed if the permit is for one TOTAL Y❑ N Y C3
hundred dollars IS 100)or less.) -
U O 1 certify that in the Performance of the work for which this per. CITY. MECHANICAL PERMIT FEE' FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
0.W Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex_
F Z emption,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 AIR HANDLING UNIT(OVER 10=C.F.M.) 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address �4JF
ELECTRIC
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,000E,T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lose,100,000BTUISEE FEE SCH. 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 3.001CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit MECH.CONT. LIC.NO. MECH.
2
TOTAL TOTAL
Signature of Applicant/contra., I Date
OFFICE COPY