7073 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,JE BUILDING PROJECT IDENTI FICATION PERMIT NUMBER
BUILDING o APPLICATION & PERMIT U73
AvoREsS l
i ) a � BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7
OWNER'S PLAN CHECK VALIDATION
v "AME _ OTY. ELECTRIC PERMIT FEE
P
C. T.ff&sN UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
r LIC.NO ILIGHTING FIXTURES 5.00/1.00
!
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
/
ADDRESS
y� PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,60 PLAN CHECK FEE P.C.NO,
OR
ENGINEE
ZV 4�U I/1 SIGNS TRANS. 3.00
DOOHf55 Ervc. SPECIAL CIRCUIT 5,60 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 n
APPLICANT'a MOTORS SEE FEE SCH.
AODRLSS 30 7 $ . r�fL.�
SERVICE RANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
a v u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
vv,Q Iffi Icummencing with Section 7000)of Division 3 of the Husiness and BLDG. -ELECT. PLG. MECH.
F D z Professions Code,and my license is in full force and effect ❑ ED 11 ❑
z 0 m- Litems ClassLic.Number
0 z F w Date Contractor
a r E BUILDING PERMIT
Ie w a OWNFILIHJ(.DER DECLARATION INFORMATION
K ado MISC.- REFER TOORD
3 N I hereby aflum Ilial I um exempt from the Contractor Liccnsc
F _ Boort.not Professions PERMIT ISSUANCE 600 VALUATION S/FT.
uOj law for the fUllowmg reas'un.ISec.703LS. .1F
Code:Any city or county which reyuiresa permit loconstrucL alter,
re ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
is R 0 LL reclubus the applicant for such permit to fil...igned statement that TOTAL�/ PERMIT TO
w m he is licensed pursuant to the provisions of the Comnaclor's License >
F z a
Law(Chapter9(commencing with Sectio"7000)of D7
ivision 3 offle Tt'Nj�J ELGZ
business and Professions Code)or[It.[he is exempt therefrom and OTY. PLUMBING PERMIT FEE
rC H Oo the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant fora permit subjects the applicant loacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than rive hundred dollars(S500L)
❑ 1,as owner ol'tire 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:"fire Contractor's License law dols not apply to an owner of
pm perry who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
,dents are not intended or Offered for sale.IL however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,(be 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 CON PB Other
rout or purpose of sale.). I NDUSTRIAL WASTE INTER. 20.00
1,as owner of the property,am exclusively contracting with El ❑ El El 1:1I'. nseJ contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:I'he Contractor'.,License law dues 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 contmcloNs)licensed PUMUmL to -
tire Contractor's LicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt Imder S ;H.&P.C.for this WATER HEATER W/VENT 4.00
reatiV 11
Owner �1a1e WATER SYSTEM 4.00
ACC.DATE ACL FILE NO.
_ WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1-hereby affirm Ola[l have a cerlifcatc ofc.P.Nt 10 self-imnuc, - ZONING
or a cerjiftcale of Workers'Compensation Insurance,or a Certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company x
Q FJ Certified copy is hereby furnished FIRE SPRINK ENERGY L24
Z Z fl Certified copy is filed with lire city inspection .ivini"n. MISC.- REFER TO ORD.
E] NE] Y ❑ NE]CC W Cl:R I'IPICATE Op Ii XEMI'IION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Lu.C.
LU aw,COMPFNSA'IION INSURANCE PLO.CONTR. P LIC.NO. PLG.
d O ('Phis .bion need not be completed if the permit is In,one TOTAL Y❑ N❑ I Y❑ N❑
Z� handred dollars($100)or less)
U O beertify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as in
U become subject to the Workers'Compensation laws of California. BUILDING
a Ume npplicant ALTER OR ADD TO MECH. 4.00
} N NOTICE 10 APPLICANT: If,atter making this Certificate of Ex-
F_ 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 10MC.F.M) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 5.00 SEISMIC FEE
I hereby affirm that that is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
Phu 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.(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC a1
I certily that l have read this Application and slate Hal the above VENTILATION FAN (SINGLE) 3.00
• information is correct.1 agree to comply with all city and county
oPLUMBING
rdins ances and state lawretailing to building construction, and BOILER-DOW H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abuvomenlioned 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accr c -•sins aid ity in couseyuene ol'ihc
gr go his per MECH.CONT. LIC.NO. MECH.
(/ uS TOTAL TOTAL
PIN ure of App' n C nImclor e
INSPECTOR COPY