1541 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY !%^
BUI LDI NG PROJECT 1 DENTI FICATION PERMIT N E0 I
BAADDRESS
APPLICATION & PERMIT 41
ILDIN I BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNERS- _ -- -�--' - -•_i' i'-(" - _ PLAN CHECK VALIDATION
ME OTY �'''t 'ELECTRIC+PERMIT
,
NAMERAGT �. UTLETS-SWITCHESRECEP +5.00I7.00
LIc. 1Z3 LIGHTING FIXTURES 5.00/1.00
MNTR AC
oRs
ADDRESSDRESS APPLIANCES-RESIDENTIAL 4.00
v 2P:7—VG7.. PANELS 5.00 DATE OF APPLICATION
%Be HITECTPLAN CHECK FEE P.C.N0.
OR .
ENGINEER
LOC.ND. SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIAL CIRCUIT Tj,QQ PERMIT VALIDATION
AO DRESS
ZIP EMP.METER OR POLE INS. 15.00 {� '
APPLICANT s MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE t1 10.00 p
0 0 o LICENSED CONTRACTORS DECLARATION
< v v I hereby affom that I am licensed under provisions of Chapter 9 - ISSUANCE GATE
y , a Icommencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
i ProfessionsC ,a license is in full j g S¢f ❑ ❑ ❑
Z i W License Cla Lie Numbers 3 ` 7
F N L J IF Contractor
¢ , 2 , - I•-,'BUILDING'TERMIT;;;;_4T
¢ a, w OWNER-BUILDER DECLARATION >•+,;"?r,INFORMATI ON;n ax.i t
o A r _ EFER TO ORD
a'u1 s- 1 hereby affirm that I am exempt from the Contractor's License MISC.— +„ _
3 y y P VALUATION S/FT.'
u o ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit o construct.alter,
ac ¢< 2O improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
E m M requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
F ' > Law(Chapter 9(commencingwith Section 7000)of Division 3 oftlic
¢ Business and Professions Code)or that he is exempt therefrom and QTY: �` tT. " PLUMBING PERMIT FEE'
¢ =$ the basis for the alleged exemption.Any violation of Section 7031.5 "':� "+' ",. t A"T'.' '.", >' -' STORIES TYPE CONSTR.
i3 by any applicant for a permit subjects the applicant toacivil penally •,ALTER-DRAIN&VENT-WATER (EA.) q,00
of not more than Ove hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.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 does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES•PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
- � roemS are of ugh intends ownemployees,for sale.
If,ed that however.
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ Cl ❑ ❑
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.) 1,00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec..,B.&P.C.for thisWATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4,00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofcmnsent to self-insure. ZONING ENG.SITE NO.
//oiPrr a certificate of Workers Compensation Insurance,or a cerlified
APCII Ih . pany�"
O p Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z O pI(s��Cenified copy is filed with the city inspection division. MISC.• REFER TO ORD. ❑ ❑ ❑ ❑
A lie nt Y N Y N
Hy PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
� CERTIFICATE OF EXEMPTION FROM WORKERS'
W ? COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ,..., Y❑ N C] Y [:] N❑
CL O (This section need not be completed if the permit is for one TOTAL
U O hundred dollars(S100)or less.) - + - t +r ?ye ., - t �y
I certify that in the performance of the work fur which this Per OTV " MECHANICAL PERMIT II FEE 4 `.FEE'SUMMARY sli Y'
LL F mit is issued.I shall not employ any person in any manner so as to , ;;y- • -
O W become subject to the Workers''Compensation Laws of California. - BUILDING
Q. Date Applicant ALTER OR ADD TO MECH. 4.00
>_ N NOTICE TO APPLICANT: If,after making this Certificate of ET
2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IO=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE
I 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 HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply with all city and county PLUMBING
ordinances and stain laws rioting to comply
with construction, andmy BOILER-COMPI3 H.P.Or 100,000 B.T.U.) 4.00
hereby uuthorite representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City Of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
ing oft ermil. MECH,CONT. LIC.NO. MECN. >-pJe
+ TOTAL TOTAL' ! G
r
I ur of APPlivant/Cnnrrac[nr Uatc
OFFICE COPY