2316 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERITgppLICATION & PERMIT ,3
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWN
i--,. - p 1_. Po` t �.- " PLAN CHECK VALIDATION
NAME 1 OT1 st ELECTRIC PER
AAL AMP, 1
(NONE
•
CONTRACTOR 5 OUTLETS-SWITCHES-RECEP 5.00/1.00
N ME �77
Ic.-zat5i,6 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES•RESIDENTIAL 4.00
ADDRESS
PNONE 1 PANELS 5.00 GATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN_CHECK FEE P.C.NO.
OR
ENGINEER 3.0D
Sac,No. SIGNS TRANS.
ARCN.OR ENG. S.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
A ORF35
SERVICE CHANGE 10.00 •�.o��/r/v
w
00 LICENSED CONTRACTORS DECLARATION 7
¢u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Z a (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
vs m i Licen pm Cod- n y license is in full for d f ❑ ❑
o w - Ucen Lic.Number
Z. w Dem Cantnctor
>< ( BUILDING PERMIT'-'
¢w u OWNER-BUILDER DECLARATION n 7 1'INFORMATION%;.,}++,'
A. N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD " -
ic p VALUATION S/FT.
uoa law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 / �
y0J Code:Any city or County which requires a permit to construct,alter. b
Q Q 0 improve,demolish,or repair any structure,prior to Its issuance,also ELEC.LONTR. CIL.NO. ELEC.
ii�- DLL require,the applicant for such permit to file a signed statement that TOTAL MIT TO
W
$H he u licensed pursuant to the provisions of the Contractor's License ��R t ..S/OIe//✓K
r Law(Chapter 9(commencing with Section 7000)of Division 3 of the ✓: '7e-, a ba`e s+ _`•t ;),.t •s+
`-F a Business and Professions Code)or that he is exempt therefrom and .PLUMBING PERMIT• T FEET
F t O s 4 nue. $ j;• e•{ i+J .T,. C' •''_.*a. ;q Y,r:S O EL YPE CONSTR.
¢s- the basis for the alleged orexemption.Any violation t to action etuall 1.,. . _x. -dxr, ].'1:. ,u ,Tv
by any applicant forapermitsubjects the applicant toacivil Penalty gLTER-DRAIN 4,00
DE
of not more than five hundred dollars(S500L):
❑ 1,as owner of the property,or my employees with wages as IBACK FLOW PROTECT.DEVICE 2.00 I C{j RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offend 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 IF IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL wCREAGE
r. himself or through his own employees,provided that such improve. GAS-EA.SVSTEM-11 4.00
ments arc not intended or offered for Sale.If,however,the building
or improvement is sold within one year of completion,the owner• GAS-EASYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im . RES IND CON PB Olney
prove for purpose of sale.). I N DUSTR IAL 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 INC 5 V.B. 5.00 ASSESSORSPARCEL 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 6(EA.) 1.00
Contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.W&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ALC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self insure. ZONING ENG.517E N0.
or a certificate of Workers'Compensation Insurance,or a certified
Copy thereof(Sec.3800,Lab.C.l.
Policy No, Company
0 ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T-24
Z
❑ Certified copy is filed with the city inspection division.
p: MISC- REFER TO ORD.
0 Applicant Y [3N❑ Y ❑ N❑
vy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
fY CERTIFICATE E EXEMPTION FROM WORKERS'
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL v❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.) c ic'• + _ ..+
U O I certify that in the Performance of the work for which this per. Owl :.'MECHANICAL PERMIT ' FEE; FEE SUMMARY
ly mit is issued,I shall not employ any person in any manner so as to - .
become subject to the Workers'Compensation Laws of Califomia. -- 't, -• - a
O yBUILDING S
y Date Applicant ALTER OR ADD TO MECH. 4.00 ��
} to NOTICE TO APPLICANT: IL after making this Workers'
Compensation
sa Ex-
Z emptio n you should become e. you to the Wrthwit Consp In with
qpp LIANCE 4.00 PLAN CHECK t�
provisions io the Labor Code, you must forthwith comply with FEE 7
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DC.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 5.00 SEISMIC FEE 4I
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. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.17.50 ELECTRIC
Lenders Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-CDkVi3H.P.or100,000B.T.U.) 4.00
• hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the Cityof MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and ex Penses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
ontm,o is permit MECH.CONT. LIC.NO. MECH.
S1 TOTAL c r.:•;�i•
TOTAL
.
I'Mnaturc of Appicant/Contmcto Date •-I ':." `•r r°
OFFICE COPY