7246 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN-ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A nErss / J� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7246
OWNER'$ /\J PLAN CHECK VALIDATION
NAE PTY. ELECTRIC PERMIT FEE
• PHONE
'C0VT1 FHCTOH'S
AME UTLETS-SWITCHES-RECEP 5.00/1.00
� I.C.No.4S I 54F I
LIGHTING FIXTURES 5.00/1.00
1 cONADDRESS
ACTOR'S ,!+ fl PPLIANCES-RESIDENTIAL 4.00
TR5
PHavms-bo PANELS 5.00 DATE OF APPLICATION
ARCHITECT i SIGNS 6.00 PLAN CHECK FEE P.C.NO.OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT S
ADDRESS MOTORS SEE FEE SCR.
DDREES$ t
SERVICE CHANGE 10.00 _
wo o LICENSED CON7"RACfORS UCC LARA'1'ION
¢u U I hereby affirm that 1 am licensed under provisions of Chapicr 9 ISSUANCE GATE
e, <y (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
F N z Professions Cod•,a d license is in hdl lure Ld •tee. ❑ ❑
z O w- License Class Lie.NumbEl
9 w )ate - Contractor
a r 5 �� BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
A o¢ D MISC.- REFER TO ORD
X
3 u m I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
H u o a Law for the(allowing reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6,OQ
Code:Any city or county which requires a permit to construct,alter,
VV,b
¢ 2 Q 0 impme ,demolish,or repair any structure,prior Io its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL -PERK TO
e m m u he is licensed roa ant to tile
le rovisions of the Contractor's LicenseL/ .V
Fzi
Law(Chapter 9(commencingwith Section 700()ofDivision 3 ofthe tl..` .
a Business and Professions Code)or that he is exempt 1hereGom and OTY. PLUMBING PERMIT FEE CSI /1
¢ I Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ;m by any applicant for a permit subjects the applicant Loa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
u1not more than five hundred dollars 15500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
then sulc compo nsation.will do the work,and the structure is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
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 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments arc not intended Or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 4.00
' or improvement is sold within one year of completion,tile-owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or in, RES IND CON PR Other
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
liccnmd contractors to construct the Iooivct(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
Bnd Prolbssians Code:'Ihe 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 cor ructorts)licensed pursuant to
t he Contractor's license Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
❑ I at,,exempt under Sec. ,B.&P.C.lar this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK iRS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certiGcale of consent to,dfin,u e, ZONING
ora omit iazle of Worken Compenwiion Insurance,or a cert ilio,' ENG.SITE NO
copy thereof(Sec. Cp,
Policy Nu. Coo mpaorynA
Q 1 ❑ Certified 'o, is here by fumished.q I FIRE SPRINK ENERGVyV'14
z 21 Cert if• copy Is fill, with the I ms ciion wis on. MISC.- REFER TO ORD.
rant / - 1 Y ❑ N❑ Y❑ N❑
~ w � �w'� PERMIT ISSUANCE 6.00
LU - CGR'1'IIICA'1'Ii E EXEMI'IION NS PROM WORKERS' FLOOD ZONE A.L.U,G.
lL COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Y❑ NE] Y E] N❑
� Z Idles section aced not he complete) if the permit is (m one TOTAL
hundred Joliars IS 100)or less.)
CJ O 1 certify that in the pedbrmance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mil is issued.I shall not employ any person in any manner so as to
OU become subject to the Worker,'Compmssation Laws of California. (
ED D 60
2 am Applicata BUILDING J ALTER OR ADD TO MECH. 4.00
} 0 NOIt CIi 10 APPLICANI; 11,alter making this Ce U Collate of lix-
Z pontoon, should
you should became subject m the Workers'Ccomply with APPLIANCE 4.00 PLAN CHECK t�
provisions io Lite his permit
shall
you must forthwith comply with FEE / 'fZ
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M) 3.00 ^
CONST RUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10fWC.F.M.) 5.00 SEISMIC FEE -(o
1 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. MICROFILM -
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Addle HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ss
1 verity that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 .
information is correct. 1 agree to comply with all city and co only PLUMBING
urdinanees and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby xulhorue representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(we) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against lea, judgments, costs an, exp__which CONST.TAX
PERMIT ISSUANCE 3.00
may in , ty w' ue 'gainst Said City in consequence of the
granting fill • r MECH.CONT, t LIC.NO. MECH.
I TOTAL 1
late TOTAL
Si&nu •o licani 'onir cion
INSPECTOR COPY -'