17501 (3) APRLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.i:Y BUILDING PROJECT IDENTIFICATION 'PERMIT NUMBER
oass - APPLICATION & PERMIT F 17501 7 5 O1noE1v JO <A-n A Lvein. PL BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 4.
.-
OWNEH'S
PLAN CHECK VALIDATION
"a"'I1` ` OTV. ELECTRIC PERMIT FEE '
Eifj Dl' E44164 I
CON RNCTORS
NA �, OUTLETS-SWITCHES-RECEP. 10.00I1.00
Ea
rl S11;V 0 L1C.NO. LIGHTING FIXTURES 10.00/1.00
,ONaror
ADDRESssS' (]� �(
APPLIANCES-RESIDENTIAL 4.00
y � tI� C Q
P41IONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
LIC.No. ISIGNSTRANS. 3.00
ADORES.E.G. SPECIALCIRCUIT S.OB 'PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESSPLICAr. MOTORS SEEFEESCH.
SERVICE CHANGE 20.00
DaiPAf al
.00 LICENSED CONTRACTORS DECLARATION
IS i W I hereby affirm that I am licensed under provisions of Chapter o ISSUANCE GATE
(commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
License Class-
Code,and my Ilccn se is in full force and effect. - J
0 o m - License Class Lin.Number Py
9 m f� Date Contractor of.
ag am OWNER-BUILDER nec.nRAT1oN CU��OUJ '
BUILDING PERMIT
w ;w INFORMATION
LL w I hereby affirm that 1 am exempt from file Contractor's License IMISC.- REFER TO ORD -
F u o< Law for the following reason.(Sec.7031.5,Basm.sand Professions PERMIT ISSUANCE _ 10.00 v 0 VALUATION $/FT.
m'^ Code:Any city or county which requires a permit to construct,alter, DDD
IS R 4 p improve,demolish,or repair an structure,prior ELEC.GaNTR. LIC.NO. ELEC.
p p' y r or to its issuance,also (�
nO u requires the upplicaut for such permit to file II signed statement that i TOTAL I-+ `� P MIT TO
K
$ hsu
e is licensed purmll to the provisions of the Contractor's License -
H z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe f)J, 1,
a Business and Professions Code)or Blat he is exempt therefrom and QTY. PLUMBING PERMIT - FEE - I N_ ( 0 Y`
F the basis for the alleged exemption.An violation oCSccti.n 7031.5
g P Y STORIES TYPE CONSTR,
by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not nmre than five hundred dollars(8500).): ' I t011b
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE' 4.00
their.sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code'.The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,andel t who does such work FIXTURES-PER TRAP 5.00 g:D . .ELooa a TOTAL ACREAGE
himself or through his own employees,providedthat such improve-
ments FLOOR are not intended or offered for sale.I L however,the building ' GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4'IEA.) 2.00
builder will have the burden of proving that he did not build or im. BUILDING USE
P ro for purpose ofsalo). INDUSTRIAL WASTE INTER. . 30.00 RES IND CON PB other
c I,as owner of the property,am exclusively'contracting with 11 El ❑ 0
Ii •d cc"tractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Ihercon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to SEWER-SANITARVSTORM EA.200ft/10.00
the Contractor S License aw. TRACT NO. PARCEL NO.
reason
❑ I a uxcmp w er ,li.&PA br ihl WATER HEATER W/VENT - 6.00
Owner Date .- WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKER COMPENSATION DIiCLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have it certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,of a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.0.).
Policy No. Company
O ❑ Certilied copy is hereby furnished. FIRE.PRINK ENERGY T24
Z Z. ❑ Certified copy is NN with the city inspection division. -
p Applicant misc.- REFER TO ORD. Y ❑ N F] Y ❑ N[
CC w PERMIT ISSUANCE
Lu CI!R'I'I EIC ATG OF EXEMPTION FROM WORKERS' 10.00 FLOOD ZONE A.L.U.C.
W >_ COMPENSATION INSURANCE PLG.CONTR, LIQ NO. - PLG:
CL Or (Phis section need not be Completed if the pmmil is for one TOTAL 122,I Y❑ NE] I. Y [:) NC]
D Z hundred dollars IS 100)or less.)
-U O 1 certify that in the performance of the,work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any nmmmr So as to
00 become subject to lie Workers'Compensation Laws of California. JIO So
a Date Applicant BUILDING
} ALTER OR ADD TO MECH. 5.00 N NOTICE TO APPLICANT'. If,after making this Certificate of fix-
♦- Z emption,you should become subject m life Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Cade;you must forthwith comply with FEE
U such previsions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION-LENDING AGENCY AIR HANDLING UNIT(OVER 10J C.F.M.) 6.00 SEISMIC FEE 2
I hereby affirm thin lhercJs a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,performance
Cint)ace of[lie work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 'f
Lender's Address ELECTRIC
I certify that I have read this application and stale that!be above VENTILATION FAN (SINGLE) 4.00 O
information is correct. I agree to comply with all city unJ county - PLUMBING
. ordinances and state laws relating to building construction, and BOILER-COMP(3.H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabi tes,judgments, c.SB and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may any way a cr ugoinst said City in consequence of the
On fihi, pe4 i MECH.CONT. LIC.NO. MECH.
W/ TOTAL TOTAL S�"•
Signature of App'n / ontractor Date
OFFICE COPY