16578 APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES - USE BALL POINT PEN ONLY
1BU I LDING PROJECT I DENT]FICATI ONPERMIT NUMBER
BUILDING APPLICATION & PERMIT : [I] Q
ADDRESS J I IJ
z ,fl I BUILDING-.ELECTRICAL-PLUMBING -MECHANICAL ...
OWNER'S PLAN CHECK VALIDATION
"nme QTY. ELECTRIC PERMIT FEE
CONTRACTORS :I
I� C. PHONE
OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
' I Ic.NO� LIGHTING FIXTURES - 10.00/1.00
C,o RACTOR^S1 APPLIANCES-RESIDENTIAL 4.00
ANl'J 01D / PHON !•n PANELS 10.00 DATE OF APPLICATION :.
ARCHITECT - PLAN CHECK FEE P.C:NO.
OR -- `� PANELS (OVER 200 AMP) 20.00
ENGINEER C� ��(•
L1G��'lEi\L Lc.No ISIGNS TRANS. -'3.00
ARCH.OR ENG. PERMIT VALI DATION
ADDRESS
SPECIAL'CIRCUIT 5.00
- ZIP EMP.METER OR POLE INS. 20.00 ^.
APPLICANT s
ADDRESSR - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
O o
LICENSEE),CONTRACTORS DECLARATION �[Lt
¢ v u 1 hereby affirm thai I am licensed under provisions of Chapter 9 ISSUANCE DATE -
4
so< y (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H z Professions Code,and my license u'in full force and ffect. ❑ ❑ ❑
z 0`w - License Clas,-[,�+�C��O Lic.Number31Z42b - ,
2z - 0 Date'b-i 5- Cnntmctor ''7135
c r s BUILDING PERMIT
¢ ¢ w 4 -OWNER-BUILDFR DECLARATION INFORMATION
wO a 0 MISC.- REFER TO'OR
;.LL Hm I hereby affirm that 1 am exempt from the Contractor's License VALUATION
u 0 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 S/FT.
E - Code:Any city or county which requires a permit to construct,alter, - \L,
¢ ¢ Q.� improve,demolish,or repair any st mct are,prior to its issuance,also ELEC.CONTE. LIC:N0.
E
- 0 u requires the applicant for such permit to file a signed statement that PERMIT TO -
w m he is licensed pursuant to the provisions of the Contractor's Licetlw
H z a
Law(Chapter 9(commencing with Section 7000)af Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PE I� EE
¢ H o the basis for the alleged exemption.Any'violalion of Section 7031.5 STORIES TYPE CONSTR.
n ;14 by any applicant to,a permit subjects the applicant to a civil penally ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars($5000.)'.
❑ 1,as owner of tire property,or in,employees With wages as BACK 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,AR EA,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 FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own ennployces,provided that such� not rove- GAS-EA.SYSTEM-1 INCA OUTLETS 6.00� ants are not intended or offered fur sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeof sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
O 1,as owner of the property,con 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 Cont..ant's License Law docs not IglPly
to ail owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractono licensed pursuant to
j - the Contractor's License bow. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iamexemptunder Sec ,B.&P.0 for this WATER HEATER W/VENT 6.00
reaS(111
Owner Date WATER SYSTEM 5.00 ACC.DATE Ace FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. ' 5.00
1 hereby affirm that 1 have a Certificate ofconsvnt to self-insure. i'•' ZONING
or a certificate of Worker;Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 38 ,Lab.C.).
Pompany 1!Q L NI -
❑ Certified copy ishereley furnish cd. FIRESPRINK ENERGYT-24
Z Z KCertified copy is filed with the city inspection division. C- - REFER TO ORD.' -
O Applicant MIS
_ Y❑ N❑ Y ❑ No
CC ti CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
W > COMPENSATION INSURANCE PLG.CONTR. LID.NO, PLG.
CL Z( This section need not be completed if the Permit is Ibr one TOTAL YC' N❑ Y ❑ N❑
hundred dollar,(S 100)or less I
U O 1 certify that in the performance of the work tin.which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- not is issued,I shall not employ any person in any manner so as to -
U become subject to the Worker;Compensation Laws of California. _
a Dam Appli°°ntALTER OR ADD TO MECH. 5.00 rj BUILDING
} m NOTICE TO APPLICANT.,If,after making this Certificate of rix-
� Z emption,you should become subject m the Worker;Compens:n ion APPLIANCES'- 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U sucll provisions or this permit shall be deemed revoked.- AIR HANDLING UNIT(TO 10000C.F.M.) 4.00
-CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10)000C.F.M.) 6.00 'SEISMIC FEE
I In mhy aI'fini that there is a constmction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Performance of the Work Ibr which this purnit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER l00,000B.T.U.0.50 ELECTRIC-
Landcr',Address
I certify that 1 have ead this application and state that the above VENTILATION FAN (SINGLE) 4.00 :
information Is correct:1 agoe to comply with all city and county PLUMBING,
.Mamie, and 'rt lows relating to bulldog confiucti.n. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authors representatives of this city to enter upon the BOILER-COMP (Over 100p00 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for Inspection purposes ��L
(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 10.00 O CONST.TAX
may it any way accme against said City in coi.sequence of the
ran mg ofths pe mit. MECH.CONT. LIC.N0. MECH.
d
TOTAL 3i3 90 [y� cel TOTAL
Signature ofA plicant/Contractor Date
OFFICE COPY