6149 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOHEss
` BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 6149
OWNER'S - - - PLAN CHECK VALIDATION
NAME _ CITY. • ELECTRIC PERMIT '` r` FEE '
PHONE
NANrnacro UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
.No. oU'Ll'1 LIGHTING FIXTURES 5.00I7.00 ,
CONTR
AA'
DDRESons PPLIANCES-RESIDENTIAL 4.001
'PHONE ' PANELS 11- 5.00 DATE OF APP❑CATION
Go'"' PLAN CHECK'FEE P.C.NO.
oD SIGNS .x. -6.00
ENGINEER
uc.NO: SIGNS TRANS. - 3.00
ADDRE08 SS ENG SPECIALCIRCUIT " 'S,DO PERMIT VALIDATION,
:'zIPEMP.METER OR POLE INS. 15.00
- APPUADDUCESS MOTORS" SEE FEE SCH. '
SERVICE CHANGE -00
o•0 i
r D o LICIiNSCD CONTRACTORS DECLARATION -
rt u u ,I herehy affirm that [am licensed under,provisions of Chapter 9 t O^ ISSUANCE DATE
•N Z oAi (commencing with Section 7000)of Division 3 of the Business and / ' ` BLDG. ELECT. PLG. MECH.
-H N z Professions Cm an Ly4icense is in full fu a [. '-
IF
Z — License CI Lic.Number tilt of Cupe�4i ❑ O
D m H°w' 'hate Contractor ipJ
BUILDING PERm4i'D
a w a OWN iR-BUILDER DECLARATION - INFORMAT166fNJ''11
v, I hereby affirm that 1 am exempt from the Contractor's License MISC:— , REFER TO ORD
F u o a Law for the following reason.(Sec.7031.5,Business and Professions _ VALUATION S/FT.
w0 Codu:-Anycityorcounlywhichmn
lluiresupenittuconatotcpPERMIT ISSUANCE 6.00
altm, � s-o0 OC 19E4
rt a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. OUL JC
o u requires the applicant for Such permit m file a 4gmed Statement that TOTAL PERMT. 0
a w m he is licensed pursuant to the provisions 61 the Contractor's License
i ` - p/� I�}/ of /lu
r z Law(Chapter 9(commencing with Section 7000)of Division 3oflhe - V Ea perff(1
i o Business and Professions Code)-or that he P exempt thcrefrnm and OTY. - PLUMBING PERMIT FEE
arm the basis for the alleged exemption.Any violation of Section 7031.5 v STORIES TYPE CONSTR.
a3- by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA1400
of not most,than five hundred dallms($500)J . , .
: -
❑ 1,as..net of the property, r,my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Oce.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 docs not apply to an Owner of t
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 'SO.FT.FLOOR AREA TOTAL ACREAGE
hinise3Por through his own employees,provided that such improt,.
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year oLcompletion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 - BUILDING USE
budder will have the burden of proving that Ile did not haild or iIm
Prove for purposeof sale.(:• INDUSTRIALWASTE INTER. 20.00 RES IND CON PB' . Omer
❑'�I,as owner of the property,:un exclusively contracting with I ❑ ❑ ❑ ❑ ❑
licensed contractor, 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 ovomr,olproperly who builds Or improves thereon,and wbn LAWN SPRINKLERS-OVER 5(EA.) 1.00
a'
contracts for such projects with a contrtots)licensed pursuant to - -
the ConjracrorsLicense Law:. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ laon m exempt under Sec: - - ,B.&P.C.nix this WATER HEATER W/VENT 4.00
OwInm,
Ower _ "'rhale _ WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
,. �WORKIiRS'COMPIiNSAT10N DECLARATION WATER TREATING EQUIP,,. 4.00 '
1 hereby affirm anal I have a certificate of consent to self-insum. ZONING ENG.SITE NO.
ora certificate of Workers Compen ti I sum9�p or a cepeud
copy tic scant c.3800, s'Com. !.T -,� //
Policy No!' Company _ 7.(e: " -
O (y Cert" 'opy i5 he 'fur led. FIRE SPRINK ENERGY T-34
Z p A&Cnt Itiied co is it the city inspection division. MISC. REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ rn T Cl. PERMIT ISSUANCE
0C C IFIC 'Thi OF EXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z)
Z ('Fit' ssecituo need not,be completed if the'pennit is fur'one - - TOTAL Y❑ N❑ y❑ No
hundred dollars IS 100)or less.)
U O I I certify that in the performance of the work for which this per
QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any Penner m as to .
U• become subject to the Workers'Compensation laws of California.
O a Umc Appllcanl' ALTER OR ADD TO MECH. 4.00 - BUILDING aJ'
} rn NOTICE TO APPLICAN 1': If,after making this Certificate of.lix-
♦— ? emption,you sUauld become subject to the Workers Compemetlun APPLIANCE 4.00 PLAN CHECK -
' 'provisions of the Labor Code, you must forthwith comply with FEE
(� ,such provisions of this pennil shall be deemed revoked.- AIR HANDLING UNIT(TO 10SWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.RM.) 5.00 SEISMIC FEE,
1 hereby affom.that.�hcm is A cmistivaimi lending agency for EXHAUST HOOD(WITH DUCT) 2,00
., the performance of"lhe.work for which this permit is issued(Sea MICROFILMS
3097,Civ.C:): - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - HEATING UNIT 100,000 B.T.U.)7.50 - !
Lender's Address ELECTRIC ;E
I certify that l have Cad this applical ion anti slate that theabove VENTILATION FAN'(SINGLE) - ,3.00
information iscorrect. I agreetocomply with all city and county - PLUMBING_•',' -
ordioances and state laws.relating to building construction, and BOILER=COMP(3 H.P.or 100,000B.T.U.).4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SUCH. MECHANICAL
above-mentioned properly for inspection purposes. A.
(We) agree cove, indemnify and keep harmless the City of MISC.- .REFER TO ORD.;
Cupertino'against liabilities dgments, costs and expenses which CONST.TAX z
,�B PERMIT ISSUANCE 3.00 •"•-
, may in' 'y wa! ecru •13inst sat City in consequence of the .. --
gmptingofth Erol it MECH.CONT. LIC.NO. MECN
3 . TOTAL TOTAL
lognatyreyf/Appil 14
canT70ontracter Date
• - OFFICE COPY -