7070 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FI CATION PERMIT NUMBER
/n BUILDING APPLICATION & PERMIT
Y_ ADDREss:�?,4044 &Ae Al, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 070
onior.B '! PLAN CHECK VALIDATION
NAME /�� y '� Q / �1� TY. ELECTRIC PERMIT FEE
L 1 _/ PHONE 0.1�_{/-U�70/
CONTRACTORS OUTLETS-SWITCHES
NAME -RECEP 5.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 5.00/1.00
CNTRADRESS ons
ADPPLIANCES-RESIDENTIAL 4,00 -
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
On
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDREOR SS ENa, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLI
ADovssANTS
s MOTORS SEE FEE SCH.
` \
SERVICE CHANGE 10.00
wo o LICENSED CON TRACTORS DECLARATION
¢ v p 1 herehy affirm that I am licensed under provisions of Chapter 9 ISSUANCE J E
Na N Icon.numcing wish Section 7000)of Division 3 of the Business and BL ELECT. PEG. METH.
so H z Professions Code,:rad my license is in full force and effect ❑ ❑ ❑
z O m - License Class Lic.Number
-
0 ,A r
O Date Contractor
a x LDING PERMIT
¢ ¢ w a OWNER-BUILDFR DECLARATION INFORMATION
MISC.- REFER TO ORD
w 3 u r I hereby alfinn that I am exempt from the Contract.,',rector License VALUATION $/FT.
H u_o j Law for the following reason.(Sec.7031.5,Busiressand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
¢ K Q improve.demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
S m ¢ retluires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to tie provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 offle
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
R IOo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
`o ;m by any applicant for a Permit subjectsthe applicant ma civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars 0500).):
❑ 1,as owner of tine Property,or my employees with wages as SACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP REB.UNITS
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 Low does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his we em Ployecs.provided that such improve-
nems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year o1completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
buil r will have the burden of proving that he did not build or im- . . . RES IND CON PB OrM1e,
ro c for purpox of sale.). INDUSTRIAL WASTE INTER. 20.00 El ❑ El ❑ 1:11.as owner of the property,ran exclusively contracting with
If P'd contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
a d No1'cssum,Code:'1'hc Con tractor's License Law docs not apply
to;in owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contradovs)licensed Pennant to
He Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I ameseml under See .B.&P.C.fort is WATER HEATER W/VENT 4.00
reason
Owner Date/ WATER SYSTEM 4.00 ACC.DATE ACC FILE No.
WORKI S'COM ,NSAilONDECLARAT - WATER TREATING EQUIP. 4.00
1 hereby affirm -u certificate of enmem to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified
ENG.SITE NO.
c;,rpy thereof(See,3800,LIxC.).
Policy No. Company
O ❑ 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.
O Applicant Y❑ N❑ Y ❑ N❑
cc N CERI'IPICA'I'C OF IiXFMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d V❑ N❑ Y❑ N❑
O f1'his section need not he completed if the permit is for one TOTAL
Z hundred doll ars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any manner ,,as to
U heco.Be Object to lsjbe Workers'Com ensmion laws of California.
'O w p BUILDING
Q. Date ,1pplicam ALTER OR ADD TO MECH. 4.00
} ED NOHICF 1"O APPLICAN"T: If.after making this Certificate of Ex-
Z mutation,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 pon d,ior,or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000C.F.M.1 3.00
CONS TRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that therm 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.f HEATING UNIT(TO 100,000 B.T.U.) 4.00
Landers Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
.- hereby authorize representatives of this city to enter upon the BOILER-COMP (Over IWWO BTU)SEE'FEE SCH. MECHANICAL
nbovemcdimncd properly for inspec Erin 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
grantingf this permita n , MECH.CONT, LIC.NO. MECH.
4 TOTAL TOTAL
XSigna re yrAppIlligimliContonclor x Dale
INSPECTOR COPY