6979 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT X979
AUILDIN
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwN[R'S PLAN CHECK VALID[TION
OTV. ELECTRIC PERMIT FEE
`HONE7 3
CONTRACTORS
NUTLETS-SWITCHES-RECEP 5.00/1.00 J ` �f
AME
�j Llc.No. LIGHTING FIXTURES 5.00/1.00
NTHACaGRS
OREss APPLIANCES-RESIDENTIAL 4I .00
-}
- K HONE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHELK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
A IIP [IFEMP.METER OR POLE INS. 15.00 /
APPUCANTS . MOTORS SEE FEE SCH. CLI
t((4I
Roofless
SERVICE CHANGE 10.00 �7�5
ce
o o LICENSED CONTRACTORS DECLARATION
-
a u U I hereby affirm That I am licensed under provisions of Chapter 9 ISSUANCE DATE
O1 (conr Toeing with Section 7000)of Division 3 of the Rosiness and BLDG. ELECT. PLG. MECH.
D i Professions Coyy((�':uuI II y lice se is in full fore9yly pf1 t S
z oro Licnuc ClassO}b_S lice
Numbcr�27s:Q`s� v ❑ ❑ ❑ ❑
o_ _o Date Contractor e:
E BUILDING PERMIT
Ic ce4 OWNER-BUILDER DECLARATION INFORMATION
o. o a ° MISC.- REFER TO ORD
a, ;LL m I hereby al llo that I ant exempt Go.5 the Contmctoi s License VALUATION $/FT.
r .. oa Law tilr lheCollowing reason. ]031.5.I3usinasand Professions PERMIT ISSUANCE. 6.00
Code:Any city or county which requiresapermit to construct.alter.
or > 2 improve,demolish.ormpairany structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License T`-s
Hii
Law(ClmpP,9(con tmencing with Section 7000)O Division 3 ofthe
a Business and Professions Code)or that he is excmpl thcref}om and CITY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 +-STORIES TYPE CONSTR.
c ; `0 by any applicant lot a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than Ove hundred dollars($500).):
❑ 1,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 nut
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors 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 TOTALACREAGE
• himself or through his own einployees,provided that such improve-
meats ore not intended or offered side,for sIf,however,the building 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 h . . .
lie not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 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. 5.00 ASSESSORS PARCEL NO.
and Professions Codc:The Contractor's License Law does not apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts 1'01 such Projects with a contractims)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 O TRACT NO. PARCEL NO.
❑ lam exempt under See.-,BAP.C.Iisr this / WATER HEATER W/VENT 4.00
Tea.
Own) Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA I ION DECLARATION ' / WATER TREATING EQUIP. 4.00 -5Z
I hereby affirm that I have a cerifcate nl consent m ulf-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy Ihcre f�ff��yy..3�Q(1.Lab.CJ.
O xPolicy No��(.AL.NsmPanY�
ID CTaificd copy is hereby fu I 'hed. FIRE SPRINK ENERGY T-24
Z Z >C Certified ropy filed lth t xtiity ij�ji cti n division.
p Applicant J MISC.- REFER TO ORD. v❑ N❑ Y ❑ N❑
y�x C.IiRTI PICA' ti UE BXf h1I'TION PROM W'ORKI-RS• PERMIT ISSUANCE 6.00 (es FLOOD ZONE A.L.0 c.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.' E
CL 0 T]is section Tut not be completed if the permit is for one TOTAL r� Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars 15100)or less.) '
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall nm employ any person in any manner Mr as to
O0 become subject to the Workers'Compensation Laws of California. ..f a
Do Date-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} DO NOI'ICE'1'0 APPLICANIS If,utter making this Certificate of E
F Z enlption,you 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 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10EIMC.F.M.) 5.00 SEISMIC FEE SZj
I hereby affnn that there is a construction lending agency I.. EXHAUST HOOD (WITH DUCT) 2.00
the pertinmance of the work for which this permit is issued ISec. - MICROFILM
3097,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lendecr's Name H EATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city cad county PLUMBING
ordinances and state laws relating to building construction, and BOILER-DOW 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 Iwrmlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costa and expenses which CONST.TAX
may in any way accrue against said City in Consequence of the PERMIT ISSUANCE 3.00
granting his permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 744
b\' Sig ore of ontractor ate
INSPECTOR COPY .•