8473 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY is
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AD S� 042 ,t` 8,5CAA•` )1� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8473
OWNER'a n ` S PLAN CHECK VALIDATION
•
NAL6_(>0V 11 PHONE 7 7 39- OTY. ELECTRIC PERMIT FEE
NA rR�AperoRs f? _ C f�LOUTLETS-SWITCHES-RECEP 10.00/1.00
1" t 1 Le.NO. �" LIGHTING FIXTURES 10.00/1.00
CONTRACT 'S Q
� ` �1 - / APPLIANCES-RESIDENTIAL 4.00
` M" C'01C/a PHorvE 70� -1 P 10.00
p PAIN rl DATE OF APPLICATION
oqunTecr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 t
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. 1 1�
t SERVICE CHANGE I -20.00
D 0 TEMP.POLE r, A' / 30.00
a'O o LICENSED CONTRACTORS DECLARATION
a v w 1 herchy affirm that I ant licensed under provisions of Chapter 9 �/ / ^
w a n (commencing with Section 7000)of Division 3 of the Business and t ISSUANCE DATE
F y i I'rofessirreC de.✓si%p1 icense a in I'u cegnfn Igr (..' n(�. �� BLDG. ELIEC PLG. MECH.
z o,A - Li¢nx s y.Number
E,w H Dam Contractor v i�
a m 2 � BUILDING PERMIT
wa OWNER-BUILDERDECLARATI N INFORMATION
MISC.- REFER TO ORD
w 3 u y I hereby affirm that I urn exempt from the Crntru<rur's License J. /I
e- o j Law for the following reason.(Sea 7031.5,Businessand Professions VALUATION S/FT.
L - g PERMIT ISSUANCE X10"00 //�
Code:Nry Gay or county which requires a permit 10 construct,after,
Q 4 0 Improve.demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. -2 LIC.NO. ELEC.
u m K mquircS the applicant fur such c. permit to file a signed sl'vlcmcnt that TOTAL pEq MIT TO
A w he is licensed pursuant m the provisions of t he Contractor's License [/•lQ
Law(Chapter 9(comnwncingwAh Section 7000)of Division3ofthe -f r
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE �"�
X i 0
H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Is, by any applicant for a permil subjects the applicant to a civil penally
of not nmn•than live hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 Occ.GRouP RES.uNITs
their sole contpeastdirn,will do the work,and the,in I re.is not
intended or offered for sale (Sec. 7044, Business mal Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
I . property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such im procb
ments are nor intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner GAS-EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that h . . .
e did not build or inp BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CDN PB Omer
❑ I,as owner.lithe property.am exclusively contracting with . .
1:1 ❑ ❑ ElEllicensed 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 docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor+License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ tum cscmpt under Sec.-,jL&P.C,for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORK F RS'CONt PENSAIION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby atTimt (fm I have o certificate of consent to self-insum,
or a cerlificate of Workers'Compensation Insurance„or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
U ❑ Certified copy is hereby furnished.
z Z ❑ Certified copy is filed with the city inspeclinn division. FIRE SPRINK ENERGY T]4
FO Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
h CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
W COMPENSATION INSURANCE! PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
::) 2 hundred dollars IS IOU)or less,
U O I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I Shull no t persrr�rnr p so os to
bccol s d loci orkers'C cn,'at in L' vs dornia.
U i r r
U Go Dmc1A1'1!1
ppliT: I ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICIi O AI'I'LICANT: If,after ma'ng his er I to of Gx-
Fz emption,you should become subject to l e Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwilh comply with FEE
U such provisions or this,rmit shall he dcenmd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that [[lure is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Performance of rbc work for which this permit is issued(Sec. MICROFILM
3097,Civ,CA HEATING UNIT(TO 100,000 B.T.U.) 8.00 )
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.0.50 ELECTRIC
I ccrlil'y that l have read t his application and slate 11,11 the above VENTILATION FAN (SINGLE) 4.00
A information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws refiling to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby luth...ed representatives forms of this city to enter upon the BOILER-COMP (ova,ioolow BTU)SEE FEE SCH. MECHANICAL
hereby oullio ed properly for inspection purposes 1..
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
'ny wa 'rue a ,lost id CiIy in consequence of the PERMIT ISSUANCE 10.00
gran' ,this pc i �� TOTAL TOTAL MECH.CONT. LIC.NO. MECH.
oLt
Signature IRA
tic it/
Gmtructor pqs/4 D to I I (
APPLICANTS COPY
_ I