C 8455 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
BUI4.DINGPROJECT IDENTIFICATION' - PERMIT NumaER
BUILDING ^ APPLICATION & PERMIUFEE
,ADDRESS I 41vo0 e( �• C/o BUILDING-ELECTRICAL-PLUMBING- ICA / 8 4 55
PLAN CHECK VALIDNamE OTY. ELECTRICPERMITEEONE /CONTRACTORSAME . rNnnn a �/� (j UTLETS-SWITCHES-RECEP 10.00AA L/� r l• uc.NoQ LIGHTING FIXTURES 10.00 ,C,0 RACTORS 'AooREss PPLIANCES-RESIDENTIAL PHONE PANELS f 1DATE OFAPPLICATION
ogcHlracr PANELS (OVER 200 AMP) PLAN CH ECK FEE .C.NO.
ENGINEERUC.NO.. ' SIGNS TRANS.ARCH.OR ENG. - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT ZIP EMP.METER OR POLE INS. 2 '�avvucarvrsADDRESS MOTORS SEE FEE G 91,q 1 e_ SERVICE CHANGE .2pZ/LICENSED CONTRACTORS DECLARATION TEMP.POLE 3P"^� O
x
a o O I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANC
EQUALE
n <w (commencing with Section 7000)of Division 3 of the Business and B E MECH.
o Z Profession Cud endo license is in full for lid a fe �-r
Z z=o Lice" Lic.Number�J_ -
Date -
< 4
w a . OWNfi R-BUILDER DECLARATION
o A o - CI`T INFORMATION
X ; y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
FLL04 Law for the following reason.(Sec.7031.5,tlusinessund Profess ions PERMIT ISSUANCE J 10.00 VALUATION $/FT.,
f `A �4 Code:Any city or county which requires a permit to construct,atler,
a to improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E e, requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO .
F=¢ hews(Chapter
pursuant
encin
provisions of the )oContractor's License AN(S'UG Sf7a`a-f
Y Bus
(Cha nd Professions
Code)or Section is ex of t the therefrom
the
f a: O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ 1- $ the basis for the alleged exemption.Any violation of Sediun 7031.5 STORIES TYPE CONSTR.
d ; by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred'dollmG(5500).):
❑ 1„as owner of the property,or my employees with wages asn
their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT.DEVICE' 4.00 OCC:GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:floe 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 5.00 SQ.PT.FLOOR AREA TOTAL ACREAGE
•� himself or tet ince his own employees. le.11,ho that such improve-
oments.,A rimprovemenmendedor withi one year
11,however, building - GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion;the owner-
builJer'will have the burden Of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Prove
. 30.00 for purpose ofsale.). INDUSTRIAL WASTE INTERRES. IND CON Pa - Other
❑ I,as owner of the property,am exclusively contracting with 13 11 11 ❑
licensed contractors 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 La_w'does not apply
to an owner of property whti builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant t0 SEW ER-SANITAR V-STORM EA.200ft/10.00 _
the Contractors License Law. TRACT NO. PARCEL NO.
13 am exempt under See..,B.&P.0 for this WATER HEATER W/VENT - 6.00
reason
Owier Date WATER SYSTEM 5,00 -ACC.DATE 'ACC.FILE NO.
WORK ERS'COMPENSATION DI7CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have'a certificate of consent to self-insure, -
or x certificate of Workers'Compensation Insurance,or a certified ZONINGENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy NO. Company'
0 ❑ �,tit,Pied Copy is here by fu fished FI RESPR INK ENERGY T 24
Z Z IYCerti oP Me v' 1, t c ity inspection division.
Ap0licunt-� MISC.- REFER TO ORD. YE NF] YE] N[
~ N PERMIT ISSUANCE 10.00
� — Cf:R'1'IF LATE OF EXEMPTION FRO WORKERS' FLOOD ZONE A.L.U.c.
UJ > .COMPENSATION INSURANCE' ” PLG.CONTE. LIC.NO. PLG.
CLQ (This section need not be completed if the permit is for one TOTAL Y 0 N Y N❑
::) Z hundred dollars 1$100)or less.)
U O 1 certify Ihm in the performance of me work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any mannerso as to
U W become subject to the Workers'Compensation Lows of California.
a
Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING �di,J�
} m NOTICE TO APPLICAN'i alter making this Certificate of nix
H ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor'Code, you must forthwith comply with FEE pZs
U such provisions or this permit shall be deemed revoked 00
AIR HANDLING UNIT(TO 1Q0CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6A0 SEISMIC FEE
I hereby affi'inBBC there is'a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Cie C.I - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I ceriify That have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n cs,ate l L agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction,nd co and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 1,
hereby authorise representatives re this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
mooned property forinsp of this
purposes.
(We) agree to save, Indemnify and keep.harreless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' CONST.TAX
may in any way accr a•'' st said City in cons luence f the PERMIT ISSUANCE 10.00
tog Of this peimif MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL' jco
gn ore o Ic 't/ onired r ate
OFFICE COPY