0982 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PR a BER
BUILDING APPLICATION & PERMIT 0982
AD RES
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
`'�'-- '"ni'� PLAN CHECK VALIDATION
ff
NE q M1
" E QTY. ELECTRIC PERMIT' FEE
CONTRACTOR S OUTLETS-SWITCHES-RECEP 5.00/1.00 -
AMEY�/� I,
' I r C LIC.No. 3y7y33 LIGHTING FIXTURES 5.00/1.00
TRAOTO s PPLIANCES-RESIDENTIAL 4.00
on ass
a1 PHONE 7;7-CV(O
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.ND. ISIGNS TRANS. 3.00
ARCH.oR ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE
SERVICE CHANGE 10.000.00
. w O O LICENSED CONTRACTORS DECLARATION
< U u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y ¢ n commencing with Section 7000)of Division 3 of the Business and B�L]D]G�.. ELI�ECT. PLG. MECH.
r vi i Professions Code,and my license is in full forcf�satlt j L� [
z o w- Licenu Lic.Numher ��TT
9 T r o Date Contractor
a x s 3r'BUILDING PERMIT:.:^
Be w Ri OWNER-BUILDER DECLARATION t`''• "'ci INFORMATION r
o ° MISC.- REFER TO ORD
w ;u r -I hereby affirm that I am exempt from the Contractor's License
u.0 < Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
r _ N 6.00 a SB
Cade:Any city or county which requires a permit to construct,itleq
R ¢ Q Q improve,demolish,or repair any structure,prior l0 its issuance,also ELEC.CONTR. LIC.N0. ELEC.
- G u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License g /� � �A
H re i Law(Chapter 9(commencing with Section 7000)of Division 3of the 3 ` }4s.... A r .r ^t r r^
- a Business and Professions Code)or that he is exempt therefrom and CITY: PLUMBINCI'PERMITm y'i%i d a s. "FEEn=
at F $ the basis for the alleged exemption.Any violation of Section 7031 5 .. .`' ft h''-4 4.e= t fl r't='v STORIES TYPE CONSTR,
a ; _ by any applicant for a permit subjects the applicant me evil penalty -ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).)'.
❑ 1,as 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 dues such work FIXTURES-PER TRAP 4.00 S0.FT.FLOOR AREA TOTAL ACREAGE
. mems are not inthrough ended
ownemployees,forssle.If,ed that however,the
improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
maims are notinte nded oroffered for sole.If,however,the building If
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- RES D CON PB Other
prove for purpose ol'sale.). INDUSTRIAL WASTE INTER. 20.00 �❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 IN B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply .
to an owner of property who builds or improves thereon,and who LAWN SPRINKL (EA.) 1.00
contracts for such projects with a contractor!sl licensed Im Oman to
the Contractor's License Law. SEWER-S40A -STOR 200ft/6.00 TRACT No. PARCEL No.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER / E T NO-
reason
Date owner WATERSVS 4.00 ACC.DATE ACC.FILE No,
WORK ERS'COMPENSATION DE LARATION WATER TREATING 4.00
1 hereby affirm that I have a certificate of consent ,. If-i are. ' " ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance
copy thereof(Sec,3800.Lab."I.
Policy No. Company
O ❑ Certified copy is herehy furnisVISL FIRE SPRINK ENERGY T 24
Z
❑ Certified is w' I ci 'nspection division. MISC.- REFER TO ORD.
Q Applicant Y ❑ N❑ Y ❑ IN
E- y PERMIT ISSUANCE 6.00 O?.. FLOOOZONE A.L.U.C.
Lu - CE RTIFI .TE E EXEMPTION FROM WORKERS'
W � COMPENSATION INSURANCE . PLG CONTR LIC NO. PLG !) a
CLO (This section need not he Completed if the permit is for one I .TOTAL v❑ N❑ -IY ❑ N❑
hundred dollars(SI00)or less) " -: ,
V O 1 certify that in the performance of the work for which this per { ' * r x 3 '" F T t "Y 1 -FEE BUMMARY
CITY: .MECHANICAG PERMIT f_ FEE `
W H mit is issued,I shall not employ any Perron in any manna o as to yL t A-y - µ4 K r " 4.}& } +-3., . ^ ' -'
U becot�:g�We Workers'Co rma.
0 y Date!( Applicant ALTER OR ADD TO MECH. 4.00 Y BUILDING
} N NOTICE TO APPLICANT: I ,afte aking this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 4,00 PLAN CHECK p
provisions of the Labor Code, you must forthwith comply with Q
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,DWC.F.M.) 3.00 FEE e?J;
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10IMCC.F.M.) 5.00 SEISMIC FEE
1 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(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.l. \
Lender's Name
Lender's Address H EATI NG UN IT(OVER 100,000 B.T.U.)7.50 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 Y�
ordinances and state laws relating to building construction, and 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 SCH. MECHANICALvl
above-mentioned property for inspection purposes. S
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichPERMIT ISSUANCE 3CONST.TAX
.00 /
may in any way accrue against said City in consequence of the !y1
grand Df If IL MECH.CONT. LIC.NO. MECH.OTA
L s TOTAL ` Vtl V
Signature W cant/Contractor Date
OFFICE COPY �)
I.