11491 f. ��. ......_-,._e_..._..�.._..._,.. ._....._ PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION t APPLICATION & PERMIT
BUILDING
ADDRESS
ILDING - ELECTRICAL-PLUMBING-MECHANICAL11401
{{
OWNER'S
. PLAN CHECK VALIDATION
"AME s �ff_l
ELECTRIC PERMIT FEE
HONE
CONTRACTO UTLETS-SWITCHES-RECEP 10.00/1.00
NAME y
L.4�� -
LIGHTING FIXTURES 10.00/1.00
CONTRACTO 'SAPPLIANCES-RESIDENTIAL 4.00
ADDRESS, {\J� `
p�{pE+ � PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P C NO.
OR
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 55,00 PERMIT VALIDATION
ADDRESS
ZIP EMP. METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 2,D.00 k
o o LICENSED CONTRACTORS DECLARATION b
~ w
C ...t I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N Q a (commencing with Section 7000)of Division 3 t epusi - and BLDG ELECT PLG. MECH
Oz Professions C 8,a n y license is in full f d f ❑ ❑ ❑Z O v - License Clas Lic.Numbero Date Contractor
- BUILDING PERMIT
w � O ER- U LDER DECLAR TI N INFORMATION
a O a MISC.- REFER TO ORD
x 3 a m I hereby affirm that 1 am exempt from the Contractor's License VALUATION S/FT.
w LL O Q Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
m n Code:Any city or county which requires a permit to construct,alter,
Qimprove,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO ELEC.
IU ao tr °requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a x m v) :he is licensed pursuant to the provisions of the Contractor's License
Z > Law(Chapter 9(commencing with Section 7000)of Division 3 of the -
a Business and Professions Code)or that he Is exempt therefrom and QTY. PLUMBING PERMIT FEE
_ STORIES TYPE CONSTR
n: i- o the basis for the alleged exemption.Any violation of Section 7031.5
a 3 m by any applicant for a permit subjects the applicant to civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECT. DEVICE 4.00 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. 5.00
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 5.00sO.Fr FLOOR AREA TorAL ACREAGE
himself through his own employees,provided that such improve- GAS-EA.SYSTEM-1 I NC.4 OUTLETS 6.00J
menis 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) 200 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. 30.00
E) E,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. 6.00 ASSESSORS PARCEL NO.
and Professions Code.The Contractor's 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO PARCEL NO
❑ 1 am exempt under Sec ,B&P.C.for this r WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a Ver(,t,
cat• f rls s' p nsation nsy ranee,o a certified,
cop} )
Polic p
❑ ili c py is hereby turn ted FIRE SPRINK ENERGY T-24
Z Z ❑ Certifie copy is filed i[h th, rty ut esti n on.
p Applicant \ MISC. REFER TO ORD. >' r .1�Y ❑ N❑ v ❑ N❑
cr N CERTI I TE OE E .MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A L.0 C
LU > OMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG
(This recti ed not he completed i the perms[ is for one
TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollar 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- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. BUILDING
Date_ Applicant ALTER OR ADD TO MECH. 5.00
>_ y NOTICE TO APPLICANT. If,after making this Certificate of F.x-
Z 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Na
Lender' me HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
s Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING `
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
s 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
m in any ay ccrue against said City in consequence of th PERMIT ISSUANCE 10.00
grang of thi per it. ECH.CONT. LIC.NO. MECH.
+; TOTAL TOTAL J
I SignotI.ire of A /Contractor It
t