8367 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT J ('�
ADORES lorlo I I BUILDING - ELECTRICAL-PLUMBING-MECHANICAL '. � 753�` 7�
OWNERS t y� Y - PLAN CHECK VALIDATION'
�1(1
N E ,wr- QTY. ELECTRIC PERMIT FEE
10 vHONE
Nomrnncroes OUTjLETS-SWITCHES-RECEP 10.0011.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S 'L APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
Lot.No, • SIGNS TRANS. 3.00
ARCH.OR ENG. ' SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
nPEMP.METER OR POLE INS. 20.00
AESrvr's
ADDRESS MOTORS SEE FEE SCH.
O(L� SERVICE CHANGE 20.00 //7
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q'� I hereby a(finn that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
FH i Professions Cade,and my license is in full force and effect. ftV
z o m - License Class Lic.Number
Q z r o Date Contractor `-
H m s'-i 'BUILDING PERMIT/
5 rt wtet OWNER-BUILDER DECLARATION
A 0 a U - MISC.- REFER TO ORD INFORMATION
wS LL H I hereby affirm that I am exempt from the Contractor's License
o. oj Law for the following reason. 7031.5,Businessand Professions pERM1T ISSUANCE 10.00 VALUATION S/FT.
r - Code:,Any city or county which requimsa Permit to construct,.alter, / O VVO-
¢ 2 Q a improve.,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. u/ V 1/
O ¢ requires the applicant for such permit to file a signed statementlthal TOTAL/ PERMIT TO ,
wm" he is licensed pursuant to lire provisions of the Contractor's License '
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofjhe
i D Business and Professions Code)or that lie isexempt therefrom and OTY. PLUMBING PERMIT FEE I'
the basis for the alleged exemption.Any social ion of Section 7031.5 1 STORIES TYPE CONSTR.
dam - by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not marc than five hundred dollars($5001.):
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Code:The Contractor's License Law does not apply to an owner M
property who holds or improves.thereon,and who does such work FIXTURES-PER TRAP 5,00 S0,FT.FLOOR AREA TOTAL ACREAGE
• himself m through his own employees-pmvid ed that such im Prove- .
mentsere throuhlot,ot A ccf ,Idforsa ovid,owevee the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 IL
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsac.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Omer
❑ 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. 6.00ASSESSOflS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
/ to an to
ner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
c tr s for such projects with a contractors)licensed pursuant to
ttic ntrador's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
1 am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
1 douse..
X Osep rl Date r-_174 WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
-1
WORKERS'COMP6 SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have u certificate of consent to self insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereoflSec.3800,Lab.0 L
Policy No. Company
O, ❑ CLnificd copy is hereby fmnkhed FIRE SPRINK ENERGY T-24
Z Z "a Certified copy is filed with the city inspection division.
O Applicant MISC.- *REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC W CERTHEICATF-OI'FXEMPI'ION 17ROM WORKERS' PERMIT ISSUANCE 10.00/, FLOODZONE A.L.U.C.
UJ COhIITNSATION INSURANCE PLG.CONTE. LIC.NO. PLG. v❑ NEI Y❑' NEI
(This section need not be completed i1' the Permit is for one TOTAL
hundred dollars(S 100)or less.)
U O 1 certify that in the pertormance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F . mit is issued,I shall not employ any person in any mmrinerso as to
O w become subject to the Workers'Compensation Laws of California.
Date-Applicant f 002
ALTER OR ADD TO MECH. 5.00 BUILDING
} r9i NO1'ICI7 TO APPLICANT: If,after making this Certificate of fix
F ? mnptiaa,you should beconm subject to the Workers Compensation APPLIANCE 5.00 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=C.F.M.) 4.00
CONSTRUCT LION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE U
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. ICROFI LM
3097,Civ C.). HEATING UNIT (TO 100,000 B.T.U.) 6.00 /
/
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ECTRIC
Lender's Address
1 certify that 1 have read this application and state that the above t VENTILATION FAN (SINGLE) 4.00
information is correct, 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this-city to enter upon the BOILER-COMP IOtt,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs cod expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in Consequence of the
grinding
off/this
permit. / ! MECH.CONT. LIC.NO. MECH.
.Iirn/ > �7-C J TOTAL TOTAL ��''¢'
'Signature of AppluegUContractor Date
INSPECTOR COPY
. I