2271 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LIN - USE L-LPOINT PEN ONLY
BUILDING PROJECT I DENTI FICA V PERMI N
BUILDING APPLICATION & PEI- :IT �I�
ADDRESS f
ansa �{'TEI/e lja' E „r, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ()t �C y�eA�t i �it„ i tTyXa It s - PLAN CHECK VALIDATION
NAME STA;-TY CITYe NaC1�ELECTRIC FERMI yTTi.,.c.l",s� y",FEE:
O1M OM PHONE '. - exp"'.' C N
CONTRACTOR'6
NAME
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
0�M v `Z` 1r a LIC.NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'6 RESIDENTIAL 4.0
Mow 11
ADDRESS
�I� l` PPLIANCES-
A
1 3 S Ib 1 da-1T(p` nl PHONE si PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.DO PLAN CHECK FEE P.C.No.
ENGINEER O ` /I J
p 1 1,4,uc,Nd� 9 yT ISIGNS TRANS. 3.00
ARCH,OR ENG. 5 DD PERMIT VALIDATION
ADDRESS • ; ,%wst , SPECIAL CIRCUIT / )
G '0&, Ln zlv EMP.METER OR POLE INS. 15.00
APPUCANrJI
s
ADDRESSMOTORS SEE FEE SCH.
IAg ; VD UI O
��L
t .Ci. SERVICE CHANGE 10.00
W IF ai LICENSED CONTRACTORS DECLARATION
a swi u I hereby affnn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H<w (commencing with Section 7000)of Division 3 of the Business and BLDG. I PLECT. PLG. MECH.
B Professions Code,and my license is in full force and effect. ❑ ❑ ❑
i as
License Class Lic.Number
y - w Date Contractor
I;{f k- BUILDING PERMIT'-•.Pe., .
>< M a OWNER-BUILDER DECLARATION "j"
oauD MISC.- REFER TO ORD f*", '.,,q,71NFORMATION!x,
t r 1 hereby affirm that I am exempt from the Contractor's License VA�LUATIoy S/FT. I
Iv OLaw forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 (�
: y Code:Any cityorcounty which requires a permit to construc6alter,
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR: LIC.N0. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL IT TO
w$ he is licensed pursuant to the provisions of the Contractor's License -
FIi
L..(Chapter 9(commencing with Section 7000)of Division 3 of the '
q o. Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT ;i-- a _.FEE'
IS H. the bads for the alleged exemption.Any violation of Section 7031 5 4e.L6 ;.+, } ^e da k ae 3x{:< s _*+e i JSy STORIES T E CONSTR.
i ; ,. by any applicant for a permit subjects the applicant toa Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 AID( _r^
of n t more than five hundred dollars(5500).):
]may L as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
t eR IPSole compensation,will do the work,and the structure is not MCIT
482
intended or offered for sale (See. 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 FIXTURES.PER TRAP 4.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
x himself or throughnot
or offend for sale.
If,ed that however.
the
improve- GAS-EA.SYSTEM-11NC.40UTLETS 4,00 �{
mems an not intended or offered for sale.IL however,the building "'fff��WFF"' ISO
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND e0 PB Other
prove far purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
131,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 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00contra7 Q
the Cocts for such ractoCLicenects Lwitha Contractorts)licenced pursuant to . SEWER-SANITARY-STORM EA.200f1/8.00 TRACTN0 PARCEL NO.
the Contactor i License Law.
❑ lam exempt under See. ,B.&P.0 rthis WATER HEATER W/VENT 4.00
eason
Date !!yy,//jj WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORK ERS'COMPENSATION DI: Aaf WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-insure,
or a cerlificam of Workers ZONING Compensation Insurance.or a certified ENG.SITE NO.
copy thereof(Sec.3800.Lab.C.). y /�
Policy No. Company - v
0 - ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
❑ N v NE]_
sn PERMIT ISSUANCE 6.00 FLOODZONE
LU
CERTIFICATEOF EXEMPTION FROM WORKERS'
W COMPENSATION not a completed
if the PLG.CONTR, LIC.NO. PLGCL . Y❑ �
Cl (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY -
LL f mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
� y Date Applicant BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 Y'a
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00 FEE y�sC•5 v
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 5.00 SEISMIC FEE I �Y
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the ork for which this permit is issued IS". MICROFILM
3097.Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name e ii � .HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address
ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information and 100
is correct. I agree to comply with all city and countyPLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or ,000 B.T.U.1 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (OW,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to ave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmen 'osis and expenses which CONST.TAX
may in any way accrue ag 'nst ai C'y in consequence of the PERMIT ISSUANCE 3.00 7
granting Of Ih' permit MECH.CONT. LIC.NO. MECH.
w I TOTAL TOTAL �I6r
Signature of Applican Co re or I1ata
OFFICE COPY
I