7273 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
.ADDRESS
. L 2Z � lu 1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Z. 3
OWNEN'S PLAN CHECK VALIDATION
•� "nmEJ C •.(�/�/\f /� QTY. ELECTRIC PERMIT FEE
r�t�\ 1Rn � nI. RONEzss-Vl-
RARIEACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
5`A.l y�__ uc NO. LIGHTING FIXTURES 5.00/1.00
AONRHAHAsDDcroms APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCITOs ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESZIP EMP. METER OR POLE INS. 15.00 �G%_
ADDRESS MOTORS SEE FEE SCH. f%j_//V'�S
AOOREss
SERVICE CHANGE 10.00 �/6
w O o LICENSED CONTRACORS DECLARATION a
a v u I hereby uffmm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m , w teonunencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D z professions��Cs,o�.d,yyyy.5yyyy��G.),�my�license is in full for an e t ❑ ❑ ❑ ❑
z o m - Licrn Cl 11 Co Numbe
BAWD
fl m vs ° 1Datc - Rmlmdm
a a s t' BUILDING PERMIT
¢ 0 a u OWNER-II UI LIIf:R DIiCLARATION.i INFORMATION
Lo I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORS
3 u �- y P VALUATION $/FT.
H u o a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
-' Code:Any city.,county which requiresapermit to construct,aheq
oimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.xf ELEC. p�U
O E require the applicant tor`such permit to file a signed statement that - TOTAL PERMIT TO
d w m o. he is licensed pursuant to the provisions of the Contractor's License y.-t
r z Te Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Ari
I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mom limn five,hundred dollars(5500).):
❑ I,its 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,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner df 'R
property who builds or improves thereon,and who does such work FIXTURES-PER TR AP 4.00 SO.FT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve-
menu are not intended or offered for sada If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . . RES IND CON PR Omer
prase for purpose of sats.). INDUSTRIAL WASTE INTER. 20,00
❑ 1,as owner of the property,am exclusively contracting with p ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'1'he Contractors 1-cense Law docs not apply -
In am Owner of properly who builds or improves Hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for projects
Law. SEWER-SANITARY-STORM
e with a contranluds)licensed puum uuIn
the ContractorsLicense SEWER-SANITARYTORM EA.200ft/8.00 TRACT NO. IPARCEL NO.
L
❑ I am exempt tinder See. ,B.&P'C'Fathi, WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'CONPENSA1 ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm Wal I have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance
.or a ceRifieJ
copy thereof(Sec.3800.Lab.C.1.
Policy No.�!1 Company
0 ❑ Certified 'fpy's her• yfurnish•d. FIRESPRINK ENERGYT24
z Z� f] t' rb 'M' rTR c yity in perces division. MISC.- REFER TO ORD.
O APPlicw v ❑ N❑ v ❑ N❑
CC T CI;R1 IFICATE OP EXIiAf I'TIUN PROM WORKERS' PERMIT ISSUANCE 1( 6.00 FLOOD ZONE A.L.u.C.
L CONI PENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG.
CL CL Z 1'1'his wetidn need not be completed if the permit is for one TOTAL Y❑ B❑ Y [D NE]
hundred dollars IS 100)or luso)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
TEL T- mit is issued,I shall not employ any person in any mannerso as to
U become subject to 01a Workers'Cmnpensation La s,of California.
U n Dme Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. ? nnpti..r,you sh.uld bee.mc subject to the Workers'C.mpemsatlon APPLIANCE 4.00 PLAN CHECK
provisions .f the Labor Code, you most forthwith comply with FEE Q ��
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCF.M.) 5.00 SEISMIC FEE e5 O
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 \
tire hon
e perance of tie work for which ITT is
permit is issued(Sea MICROFILM
3017,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above V ENTI LATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city And county PLUMBING
ordinances and state laws relating to building ction, and BOILER-COMP Q H.P.or 100,000 B.T.U.) 4.00
he,ehy authorize representatives of this city Dconstruenter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpows.
(We) agr a to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino geinsl liabilities,judgments, costs and expenses which CONST.TAX
wa
may in y y aeer'against said City in consequence of the PERMIT ISSUANCE 3.00
grantln fthi Pe TH MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL o2 40
I arc of App icant/C ractor Date I ��-
r INSPECTOR COPY