3467 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FIC N PERMIT:NUMBER
T Aooss Dco%p APPLICATION & P IT
IQNoNf ( oop 3467
P+A O L IC T BUILDING - ELECTRICAL-PLUMBING -MECHANICA
OWNER'S !,/�� PLAN CHECK VALIDATION
N
,A
1ME 11 ({.� �±�/ e (5il OTY. ELECTRIC PERMIT FEE
. NOBU I- `IR Id PRONE - 0P
CONTRACTORSUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIG.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORSAPPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5,00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECKFEE P,C.NO.
on
ENGINEER LIC No. SIGNS TRANS. 3.00
ARCH. ENG. S.DO
ARCH.OR PERMIT VALIDATION
ASPECIAL CIRCUIT
zlv EMP.METER OR POLE INS. ���o
APPLICANT MOTORS F E ACH. ` J
ADDRESS
SERVICE CHANGE 1 .0
0
H O O LICENSED CONTRACTORS DECLARATION /�
W u U I hereby affirm that I am licensed under provisions ol'Chapter') �0 C1
y < c fconunencing with Section 70001 of Division 3 of the Business anA SLOG. ELECT. MECH.
F H 3 Professions Code,and my license is in full force and effect. ❑ ❑ El z o us License Class Lia Number
Q z D Date Contractor
� '" - BUILDING PERMIT
I[ a a OWNER-BUILDER DECLARA'I']ON INFORMATION
o n I lurch affirm that I ani ser,t from the Contractors License MISC.- REFER TO ORD
p1 u 0 vt Law for the following reason.(Sec n7031.5,Bumnessand Profezions VALUATION SIFT.
H _ PERMIT ISSUANCE 6.00 "-
Code:Any city or county which requDesa permit to construe,alter,
QQ Q 0 Improve,demolish,or repair any structure."IO,to Its Issuance,also ELEQ CONTR. LIC.NO. ELEC. QL
ca
LL requires the applicant for such permit to file a Signed strt,ment that TOTAL
a L PERMIT TO ,
E:
m he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(communuingwithScc(1un 7000)of Division 3 of(hc
a Business and 1'rofcssions Code)or that he is exempt therel'nnn and QTY. PLUMBING PERMIT FEE
E x D STORIES TYPE CONSTR.
EF I o the basis for the alleged exemption.Any violation o-Section 7031.5
ar
e by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of mot more than five hundred d..11.,S($5000.):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC GROUP RES.UNITS
their sole compensation,will do(he work,and the Structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Critic: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 s0.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such ingrrm'c- GAS
or
SYSTEM-1 INC.4 OUTLETS 4.00
menu are not intended or Offend for Sale,If,however,fhc budding
or improvement is sold within one year of completion,the'owner- GAS-EASYSTEM-OVER 4 IEA.) 100 BUILDING USE
builder will have the burden of proving that h . .
ime Aid nnf built or - RES IND CON PB Omer
prove fur purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El 1:1 El E] 11
licensed
as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business I LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
Inas owner of property will)builds or 1,1roves thereon.and who LAWN SPR IN K LERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmetor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACr ND. PARCEL NO.
the Contractor's license Law.
❑ I ton ei empt u h t. .B.&P.C.for this WATER HEATER W/VENT 4.00
,..loo
>mc a% fa 3wnm WATER SYSTEM 4.00 ACGDATE ACC.FILE NO.
WORKERS'C0 PEN:s''/x1 ONn:u-ARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of convent to wif-insure. ZONING ENG.SITE NO,
or a certifica«OI Workers'Compensation Insurance,Ora certified
copy thereof(Sac.3800,Lrb.C.).
Policy Nn. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z z ❑ Certified copy is filed with (he city inspection division. MISC.- REFER TO ORD. y ❑ N❑ Y ❑ N❑
H � Applicant
PERMIT ISSUANCE 6.00 FLaOD zoNE A.L.0 c.
� CERTIPICA'f1i 01:EXIiMP`FION 17ROM WORKERS'
LU > COMPIiNSA'I'ION INSURANCE PLG.COrvTH. LIC.NO. PLO.
C o I'fhis section need not he completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
Z hundred dollars IS 100)or less.(
U O 1 certify that in (he perioulDuce of the work for which this per QTY. MECHANICAL PERMIT FEE
LL H FEE SUMMARY
mil is issued,I shall not employ any person in any manner sl)as to
0 becomesuhjc,ttoo theWnrkcrs'Conipcnsution l-aw,ol California. BUILDING
Date Applicaul ALTER OR ADD TO MECH. 4.00
}
Do NO'I'ICI.TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK /r• �'=-
provisions of the Labor Codc, you must forthwith comply with FEE u '
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
C'ONSTRUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10)000C.F.M.) 5.00 SEISMIC FEE �d
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work Or 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 UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
I Certify than l have rend this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city anJ county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction. and
hereby authorize representatives of this city (.. emer upon (he BOILER-COMP (0ven100,0008TU)SEE FEESCH. MECHANICAL
aho,c-menifoned property horn nspr,Imo pain......
(We) agree to save, indemnify and keep Imri111CSs 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 ecrnch Dens, of the PERMIT ISSUANCE 3.00
granli of
SiPenni �'- ft / MECH.CONT. LIG NO. MECH,
O/ TOTAL TOTAL 3 0 9Jf
J� tur '
Signature of Appllcmh4Contractor Dmu
OFFICE COPY