6901 .APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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1' .4 BUILDING PROJECT IDENTIFICATION PERMIT NUMBER;
BUILDING S APPLICATION & PERMIT
PLUS BUILDING-ELECTRICAL,-PLUMBING-MECHANICAL 6901
• � � �. Mp'r (fir, _ _ _ _ _ _ '
OWNERS - PLAN CHECK VALIDATION
"AME r
PHONE QTY. ELECTRIC PERMIT - FEE
�l'�'�QS I •.
CONTnACTOR'S UTLETS-SWITCHES-RECEP 5.00/1.00 V
NAME
OV$ ra- O� LIC,No: 6l� 7 ..LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
/A 6 O • N•x n PHONE Q 7/-Z Lg83 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE' P.C.,NO.
on
ENGINEER
' A uc:No. SIGNS TRANS. 3.00
H.OR ENG. - PERMIT VALIDATION
APC
ADGKOR - SPECIALCIRCUIT 5.00
_ ZIP TEMP.METER OR POLE INS. 15.00
APS
ADDDRESSRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
o O LICENSED CON'T'RACTORS DECLARATION
a
L, u I hereby ulTirn That I:,,if licensed under provisions of Chupter 9
ISSUANCE DATE
y a (commencing with Section 7000)of Division 3 of the Business and - s BLDG. ELECT. PLG. - MECH.
F w z Professions Code,aqd my license is in full force and effect. ❑ O ❑ ❑
z 0 m- Lice use Class IS Lic.Number Z
o Datc P y i��Contractor . .
O BUILDING PERMIT _
a re-w a
OWNER-BUILDIiR UIiCLARA OR INFORMATION
MISC. REFER TO ORD
w 3 LL y 1 hereby alflnn that 1 am exempt from the Contractors License Q VALUATION $/FT.
F 04 Low for the following reason.(See.7031,5,Businessand Professions PERMIT ISSUANCE 6.00 .AM
CodAnycity orcounly which requiresa permit to construct,alter,
Q e¢ < 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. "•�'•1
- 0 ¢ requires the applicant for such permit to File a signed statement that TOTAL PERMIT TOcs y
" w m he is licensed pursuant to tire provisions of the Contractor License
Hzi Law(Chapter 9(commencing with Seclion7000)ofDivision3ofthe O 0f.:(,''•'_Ln'r I .
- a Business and Professions Code)or that he is exempt therdiom and QTY. PLUMBING PERMIT FEE '
cthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of riot nu.re than l ivc huelo c]dollars(8500).},
❑ 1,as owner of the 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:The Contractor's License Law docs not apply to an owner of
properly who buiNs or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SQ ET.FLOOR AREA ,TOTALACREAGE
himself or❑rough his own employees,provided that such improve-
mentsare not intendedoroffered for sale.If.however,the building GAS-EA-SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-, GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving Ihru he did not build or On-
proveforpurpose ofsale.)' INDUSTRIAL WASTE INTER20.00 RES 'IND CON PR Other
.
❑ I,as owner of the property,am exclusively contracting wit h - ❑ ❑ ❑. ❑
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORSPARCELNO.
and Professions Cod,*1'lie 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 contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO. PARCEL NO.
Cl I and exempt under Sec.' .B.&P.C.for tilts WATER HEATER W/VENT 4.00 '
reason
Owner Date WATER SYSTEM 4.00 ACC:DATE ACC.FILE NO.
WORKERS'COMPENSA'f ION DECLARATION WATER TREATING.EQ_UIP; 4.00
• I hereby affirm that 1 huvc a"nil'ica@ of consent to self-insure. -ZOwNC ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified I,
copy thereof ISco.3800,Lab.CJ. - , �] •r 6Policy No. Company Az,\ • /Y a't.i .J 7 ' .
Q' pCertified y is hereby furnished. ' J1119 V •' FIRE SPRINK, ENERGY T44
Z Z -,I i, o file i �Ihc city inspation division. MISC.
O Avplican . ORD. Y.❑ N❑ y ❑ N❑l
CC y CERT CATE O:EXEMPTION FROM WORKERS' PERMIT ISSUANCE w' 6.00 FLOODZONE A.L.U.C.
LU COMI'IiNSATION INSURANCE PLG.CONTR. LIC,N0. TOTAL O ❑'
d O (This section need not be completed if the permit is for one - v❑ N❑ v❑ N
2 hundred dollars(S 100)or less.)
U O 1 certify that in the ptnan mance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
kL I- mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
w Dam Applicant BUILDING 3(f
a ALTER OR ADD TO MECH. 4.00 -/
} m NO'I'IC17 TO APPLICANT: If,after ntaking,this Certificate of Ex
N Z' emption,you should become subject to the Workers'Compensation APPLIANCES 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 10=CF.NL) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C-F.M.) 5.00 SEISMIC FEE
I hereby ah'irn that there is a construction lending agency far EXHAUST HOOD(WITH DUCT) 2.00 t
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Leader's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I ecany that l have read this application andstare that lila above VENTILATION FAN (SINGLE) 3.00 _
information is correct I agree to comply with all city and county PLUMBING
.Nivances uad state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city. to-enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpoecsr
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag fast liabilities,judgments, costs and expenses which CONST.TAX
3.00
may in a way accrue against said City in consequence of the PERMIT ISSUANCE
grantim his permit. MECH.CONT. LIC.NO, ___7MECH
TOTAL g
TOTAL /
ign to o Applicant/Contractor - Date
OFFICE COPY
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