7106 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT lDENT[FICATION APPLICATION & PERMIT
BUILDING � � 710 6
aT
TNG-ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME D C I72ZQTY. ELECTRIC PERMIT FEE
NTRA TO
\� r PHONE( '
c UTLETS-SWITCHES-RECEP 5.00/1.00 �
N
sec.No. IGHTING FIXTURES 5`00/1.00 /
r. NTRAc ORs PPLIANCES-RESIDENTIAL 4.00
MESS
PHONE PANELS 5.00 DATE OF APPLICATION
SIGN$ PLAN CHECK FEE 13C.N0.
sec.NoSIGNS TRANS. 3.00Ao.R ESS SPECIALCIRCUIT 5.00 } PERMIT vnu OnnoN
30 ,
zIP TEMP.METER OR POLE INSd 15.00 &L `
APPLICANT s MOTORS SEE FEE SCH.
ADDRFSSODREsS
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARA'T'ION L
G v u 1 hereby a(linn Thal I um licensed under provisions of Chapter 9 ISSUANCE DATE
w w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y Z Professions Code, y license is in full force cell.)effect. Z, W
z, O m- Liana C ss Lia Number
D w F Date _ Contractor
¢ YE _ •'' BUILDING PERMIT
e w ¢ OWNER-BUILDER DECL ( �• INFORMATION
a o d O MISC.- REFER TO ORD
w3 , 1 hereby affirm that 1 am exempt from the Contractors License
r LL O¢ Law 1'or the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUALON $/FT.
Code:Any city or county which requiresu permit toconstruct,alter,
ELEC.CONTR. LIG NO. ��J�••y5 /
¢ ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O 4 requires the applicant for such permit t0 File a signed Statement that TOTAL / PERMIT TO
a w he is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- ¢ Business and I'rol'essians Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢
to O the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).): %/V 5n1
❑ 1,as owner of the proper .or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
their sole compensation,wtyill do the work,and the structure is not /
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 19'2
Code. The 0,H,actors Littn,m Law does nm apply to an owner of
property who builds or improves thereon,and will does such work FIXTURES-PER.)RAP 4.00 sa.Fr.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,Provided that such improve- O .'(
mems are not intended or offered for sale It,however,the building GAS-EA.SYSTEM NI-1 INCA OUTLETS 4.00
or improvement is sold within ane 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- RE IND CON PB Omer
Prove for purpose of sale.l. 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 Code:The Contractor's License Law docs not apply ,'u
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3 S/ -/(0 -o/s
contracts for such projects with a contmet.00 licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 / TRACT NO, PARCEL NO.
`❑ l am exempt under Sec - ,BAP.C.for this WATER'HEATE W/VENT 4.00
•`^ reason E
•.a Owner Date WATER SYSTEM 4.00 ACC.DATE` ACC.FILE NO.
2 5Yl) KGR$;cPENS?K,N DELLA RAT ION WATER TREATIIUG EQUIP. 4.00
ZZ OO C T
hereby al Irl.. t w AlI .ml a c Cate of consent to self-insure. ZONING ENG.SITE N0.c
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lah C.). � t( A
Policy No. Company_ / A
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 2
z O* Cerlificd ) s Iilcd It the city inspection division. MISC
Alc:ua /z .- REFER TO ORD. Y E] N V❑ [:] N❑
irE CIi `�RI'114CATE OF i%Ii MI"I'ION FROM WORKERS' i
PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU.c.•
�
't LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
d-0 (This section need not be completed if the permit is for one TOTAL (i[/ Y 1:1N0
_ Y Q N❑
Z) Z hundred dollars(S 100)or less.)
r U O 1 certify that in theperformance of the work for which this per- QTY. MECHANICAL PERMIT .FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
U hucomesubjcct to the Workerti Compensation Lawsof Cabfurnia.
(] a Ume AppllcamALTER OR ADD TO MECH. 4.00 BUILDING
NOTICE 1'0 APPLICANT: If,after making this Certificate of Iix-
FZ emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be themed revoked. AIR HANDLING UNIT(TO 10JMC.F.M_) 3.00 /
CONSTRUCTION LENDING AG17NCY AIR HANDLINGUNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE O�
1 hereby unlnn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the orfo ro.allof the work lie which this Iter...it is iss (Sce. - MICROFILM
3097,Civ.C.). IL HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nameffg' HEATING UNIT(OV ER 100,000 B.T.U.)7.50 •00
Lender's AJdress ELECTRIC I C
I certify that I here rca th s application cell.)state that the above VENTILATION FAN (SINGLE) 3.00
info"ition is currecL.l agree In comply with all city and county - PLUMBING UV
ordinances and.state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby aulhorire representatives of this city to enter upon the BOILER-COMP IOse,100,000BTUISEE FEE SCH. MECHANICAL
above menlioned property for inspection purposes.
(Wr) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequene of the PERMIT ISSUANCE 3.00
gr' )I'this perm MECH.CONT. LIC.NO. MECH.
TorAl TOTAL
S, atureo A"pIh:aFt/Contractor DmFr-
INSPECTOR COPY