14272 13 Id if /0`737
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEA ONLY
-« BUI 1_01 NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT A ^ ^
ADDRESS
ISZH LF-DS wE - BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4 G G
OWNER'S PLAN CHECK VALIDATION.
NAME 1, PHONE
CITY. ELECTRIC PERMIT FEE a.1cLn-L
CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME �� (
NO. 3 �ZS3 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS LAI
j;���t,�� ��1 , �}
-1II I x/OJIAI DPHONE72��123 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALI
ADDRESS SPECIAL CIRCUIT 5.00 //99''ATIONI
G
. ZIP EMP.METER OR POLE INS. 20.00 ' {a 7
APPLICANTS ' MOTORS SEE FEE SCH. /]
ADDRESS
SABQ 7Lo SERVICE CHANGE - 20.00
wO O LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
io<n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions Code, nd my license is in full force ffetl. El
Z o L - License CIS Lic.Number
g z °w DaIn�J Contractor
a -5 %M� BUILDING PERMIT
c ¢ w o OWNER-BUILDER DECLARATI N INFORMATION
E
3 I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TOO
_LD
o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10:00 VALUATION S/FT.
RLL Code:Any cilyorcounty which requires a permit to construct.alter,
ce Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D ¢ requires the applicant for such permit to file a signedstatement that TOTAL PERMIT TO
A w m u he is licensed pursuant to the provisions of the Contractor's License -
- i Law(Chapter9(commencing with Section 7000)of Division 3 ofthe
io' Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE1,11JkUaI6
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES YPE CONSTR.
by any applicant for a permit subjects the applicant to a cNil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
/ry. Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work I L1 FIXTURE$-PER TRAP 5.00 70 so.Fi.FLUOR AREA TOTAL ACREAGE
•� himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 .
j' s,r or improvement is sold within one year of completion,the owner-
GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
C" P
builder will have the burden of proving th al he did not build or im.
^� RES IND CON PB Other
b
-i:.✓ prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am 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 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 ' SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law.' 10 TRACT NO, PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance;or a certified
copy thereof(Sec.3800,Lab.CJ. ^.- op
Policy No. Company 1-iFT '
O ❑ Certified copy is hereby furnished. 97 FIRE SPRINK ENERGY T 24
Z Z 17. CeniEe c py is Ile with the city 'nspectio0.division.
0 Applicant - -Ortb- 1�(gy, - MISC.- REFER TO ORD. Y[] NC] Y ❑ N�
~ - PERMIT ISSUANCE 10.00
� CERTIFICATEOF EXEM NFROM WORKERS' .0 'FLOOD ZONE A.L.U.c.
W COMPENSATION I 'SURANCE PLG.corviR. LIC.rv0: PLG. Y N Y N[]d O (This section need not be completed if the permit is for one TOTAL
Z) Z hundred dollars(8100)or less)
U 0 I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} on NOTICE TO,APPLICANT: If,after making this Certificate of Ex-
f" Z emption,you should become subject to the Workers'Compensation APPLIANCE GA,5 Ur 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this peR$il shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DC.F.M.) 4.00 14
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 ,S
Ole performance of the work for which this permit is issued(Sec. MICROFILM
3097,CIY.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
•:"^i'. I certify that I have read this application and state that the above 3 VENTILATION FAN (SINGLE) 4.00 IZ
information is correct. I agree to comply with all city and county PLUMBING OV
t ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 101
�••.} Ohereby authorte representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
;z93x above-mentioned property for inspection purposes.
`(i'ltfuf'i (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which q OO CONST.TAX
may in any way accrue against said City in corse, ince of the PERMIT ISSUANCE 10.00 V
anti of this p rmi[. 1 ` `v� I Z MECH.CONT. LIC.NO. TOTAL TOTAL
Signature o Applicant/ nhactor 1 Ute
OFFICE COPY