7149 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING r APPLICATION & PERMIT 1 �^y
noOREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7
0 PLL Av
OWNEfl 5 PLAN CHECK VALIDATION
NAME �• � // OTY. ELECTRIC PERMIT FEE W1,G,(/Tp PHONE q( „J.
NOAIMT CTORs UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5-00/1.00
ADDRESS roR3 PPLIANCES-RESIDENTIAL 4.00
CONTRAS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.0 NO.
' OR
ENGINEER
LIC NO. SIGNS TRANS. 3.00
AADG.ENCIRCUIT 5.00 PERMIT VALIDATION
APPLICANTS ZIP EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
'
SERVICE CHANGE 10.00
o o LICENSED CON"FRACFORS DECLARATION J
<U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
1- w z Professions Code,anti my license is in full force and effect ❑ 1:1 ❑
z o m - License Class Lie.Number
O F Date C.LIG for
BUILDING PERMIT
¢ ¢ m a OWNER-BUILDER DECLARATION INFORMATION
o A u MISC.- REFER TO ORD
X
3 LL N I hereby x(finn that I am exempt from Dm Contraaoh License VALUATION
F LL o j Law T'or the Billowing rcuson.(Sec.7031.5,Busines and Pwfesomns PERMIT ISSUANCE 6.00
Code:Any City m county which requires a permit m construct,alter,
¢ w¢'¢ 2O improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC.
-•o¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n , es he is licensed pursuant to The provisions of the Contractor's License
r ,F z i Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe /)46
14 o Business and Professions Code)or That he is exempt therefrom and OTY. PLUMBING PERMIT FEE
T (C 1- m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects are applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and The structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
O himself or through his own employees,provided that such improve- -
mentsarenotAimendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
- builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
t prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
T/(I,as$wner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
{
ITS <Qntraaon to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
anJ Prof cions Code:The Contractor's License Law does not apply
to an owner of property who builds or improve,thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contra.A Tor such projects with a contractuds)licensed pursuant to
' ? the CgYtractor',Liceme Law. SEWER-SANITARY-STORM EA.ZOD(L/B.OD TRACT NO. PARCEL NO.
1 OJl am exem under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
Owl>Er- - Date WATER SYSTEM 4.00 ACC.DATF ACC.FILE NO.
IiRS'CON1Pl:NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate olCnn,mlt to cel Gin sure, ZONING ENG,SITE NO.
- or a certificate of Workers'Compensation Insurance,or a certified
copy Olereof(Set.3800,Lab.C.). ;0-/vO
I Policy No. Company
O' ❑ Certified ropy is hereby lumished. FIRE SPRINK ENERGY T"24
Z Z ❑ Certified copy is Bled with the city inspection division.
0 Applicant MISC.- try REFER TO ORD. YE] N❑ Y ❑ N❑
Ln CfiRTll%CA'I'E OP IS%GMI'IION FROM WORKERS' PERMIT ISSUANCE ,_� 6.00 FLOOD ZONE A.L.u.C.
LU > COh1PENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is lin one TOTAL 'f' Y❑ N❑ Y ❑ N❑
:) Z hundred dollars(5 100)or less.
U 0 I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- unit is issued,I shall not Colby any parson in any manner so as to
O Ubecome subject to the Workers'Compensation Laws of California.ED BUILDING
y Dat° Apphc°ret ALTER OR ADD TO MECH. 4.00
>_ EG NOTICE "f0 APPLICANT': If,after making this Certificate of IN
F Z emption,'no 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 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 .F.M.) 5.00 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 MICROFILM
3097,CivUA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all'cf y and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize 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, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting oft 's permit s MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sig gf ore of Applicant/Contractor Dale
INSPECTOR COPY