2922 APPLICANT TO FILL IN.INFORMATION WITHIN REDLINES USE BALI_ POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION 'P RMrt ER
BUILDING APPLICATION'& PERMIT BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
722
RNE
PLAN CHECK VALIDATION
" PTY. ELECTRIC PERMIT FEE
vr(onE -3y
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
(�-� LIC.NO. LIGHTING FIXTURES 5.00/1.00
NTOIA
.ANT AcxoR's
NAME
PPLIANCES-RESIDENTIAL 4.00
a .
ad RIY, ,HONE •aPANELS 5.00 DATE OF APPLICATION
AR6HI CT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS?RANS. 3.00
_ moo Ess ENG
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
A MOTORS SEE FEE SCH.
A DURESS pRE55
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION / &A-2
¢ v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
maw (commencing with Section 7000)of Division 3 of the Business anJ BLDG. .ELECT. PLG. MECH.
F w z Professions Code,a d m license is in full forr,�ynJ yyylfe ❑ ❑ ❑
F License Class
�e Lit.Number_3� A �.�
9 r Dace Contmctor_/Ar'h` _ .
F
y s BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
dodo MISC.- REFERTOORD
w IL LL 1 hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
F LL o j Law for the following reason.(Sec.7031.$,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires o permit to corlsin en.alter,
QQ ¢ 0 improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.'
D tt .requires the applicant for such permit to file a signed statement that TOTALLL PERMIT TO
te Be he is licensed pursuant to the provisions out the Contractor's License
t r z i
Law(Chapter 9(commenceig with Section 7000nof Division 3 ofihe
f
- ¢ Business and Professions Cade)or that he is exempt otereGom unA CITY. PLUMBING PERMIT FEE
xo
re r o the basis for the alleged exemption,Any violation of Section 703 L$ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penalty . ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mon,than five hund¢d dollars($500).):
ClI,as owner o1the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 2-00 Oce.GROUP RES.UNITS
their sole compensation,will do the work.and the 4tmcturc is not
intended or offered for sole (Sec. 7044. Business and Pn1I'Csslmts DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Low doev not apply to an owner of '
property who builds or improves thereon,and who docs such work' FIXTURES-PER TRAP - 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offeredrs
foala.If.howuvcn the building GAS-EA.SVSTEM-11NC.40UTLETS q.00
m
or improvemf ent is sold within one yc3r ocompletion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int-
prove for purpose of sadaRES INA CAmer
NG Pe
). INDUSTRIAL WASTE INTER. 20.00 E IN CO • ❑ ,
❑ -1,as owner of 0e properly,:on exclusively contracting with
licensed contractors to construct Duo project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
toan owner of property'who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1-00
contracts for such projects with u contractors)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200R/8.00 - TRACT NO. PARCEL NO.
❑ lam exempt under See-.]I&RC,I'nr chis WATER HEATER W/VENT 4.00
reason
'Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'C04PENSAI'I0N DECLARATION WATER TREATING EQUIP. 4-00
1 hereby affirm that I have a certificate nfconsent losell-insure. ZONING ENG.SITE NO.
or a certificate of Workers'.Compensal inn Insurance,or a certified
copy there fIse 180,Lab .I /�,��,`.� '•1
Policy Nr�r;,gmEy-(-y�/�!(F]_LygC�/l:�
Q ❑ Cent ledcop}rsheneby fit Tniim,d. FIRE SPRINK ENERGY T 24
Z ZCeraft OOnnV t ale h I a civv f Rt/}yet i':is MISC.- REFER TO ORD.
0 �'Ip TCant -/./- - YO N❑ Y El N0
� N CERTIFICAFE 01'EXEMPTION FROM WORKFRS. PERMIT ISSUANCE 6.00 FLOOD ZONE A,L.uc.
w � CO>IPHNSATION INSURANCEPLG.CONTR. LIC.NO. PLG. Y� NE] Y � N�
CL O (This section need not be completed if the Permit is for one - TOTAL
:D Z - hundred calla..($100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
U_ H mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING ,
Date Applicant ALTER OR ADD TO MECH:. 4.00
} h NOTICE TO APPLICANT: If,after making this Certificate of Ex
F ? 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 10J)OOC.F.M.) 3.00
CONSTRUCTION LENDING AGCNCY AIR HANDLING UNIT(OV : -iV SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100, B 11p i MICROFILM
3097,Civ.C.).
Lender's Name
Lender's ...Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 '
'Non tali n 'n correct. I agree to comply with all city and county PLUMBING
do and ,tai I' relating t buildingconstruction,' and BOILER-COMP I3 H.P.or 100,000 B:T.U.) 4.00
h r by authorize pr ntativ s ol this city to t t r upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH, MECHANICAL 0
above mentioned property for inspection purposes,
:(We)'agree to save, Indemnify and keep nannies, the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE'1 3.00 CONST.TAX
may in any way accrue against said City in con cn ee of the -
granting of this permit. �1 MECH.GO T. LIC.NO. MECH
q TOTAL TOTAL
SignfTU I rR%ClI r ale
OFFICE COPY