7234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINGPROJECT IDENTIF[CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AppP E55 /'''�
L Q N BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 234
OWNERA PLAN CHECK VALIDATION
" 'E - G QTY. ELECTRIC PERMIT FEE
• ONE O
co RACTDHs UTLETS-SWITCHESRECEP 5.0011.00
LIC.N LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
Mg- PLAN PHONE - U PANELS 5.00 DATE OF APPLICATION
SIGNS Q.QQ CHECK FEE P.C.N0.
OR
ENGINEErI
uc.No. SIGNS TRANS. 3.00
ADDRESS ENG.
- SPECIALCIRCUIT 5.00 PERMIT VALIDATION
APPLICANT
an, [TEMP.METER OR POLE INS. 15-00
AooRess MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
a u w I hereby affirm that I mat licensed under provisions of Chapter 9 ISSUANCE DATE
H < (commencing with Sectio 7000)of Division 3 of the BD,tmcsS nd BLDG. ELECT. PL ECH.
H N i Professions Cml, arN license is in full(or h d ffA21. /J
i o m - License Bass Lis.NumbenY ❑ ❑ ❑
r Dale Contractor.
¢ m s -a BUILDING P RMIT
¢ is w 4D OWNER-BUILDER DECLARATION INFORMA ION
wD e. I tiereby affirm Iha1..I,am exempt from the Contractor's License MISC.- REFER TO ORD
3 '- VALUATION S/FT.
F .. oa Lew]or[be ity or countywhih(Sec.
requires a Businessand Professions PERMIT ISSUANCE 6.00
vi -a 'Code:Any city or county which requires a permit to construct,alley,
¢ ¢ a � improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONED. LIC.NO. ELEC.
D ¢ requires the applicant for such permit to file a signed statemmll that TOTAL qMl i0
u w m" he is licensed,puiseant to the provisions of the Contractor's License
H s i Law(Chapter 9(epinmencingwith Section 7000)of Division 3 of the
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
'¢ o the basis for the alleged exemption.Any violation of Section 703IS STO IES TYP ONSTR.
by any applicant forapermit subjects the applicant toacivil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
fact more than five hundred dollars(5500).):
❑ 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 not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Codee'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
himself or through his own employees,provided that such improve-
mcutsarenotintendedorofferedforsale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS.:_EA.EASYSTEM-OVER 4 IEA ) 100 BUILDING USE
builder will have the burden of proving that he did not build or int- . . .
RES IND CON PB Omer
pmvc tot purpos of,.1,L INDUSTRIAL WASTE INTER. 20.00
❑' I,as owner of the properly,am exclusively contracting withEl C1 El Q El
"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 does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5IEA.) 1.00
contracts for such projects with a co aractoHs)licensed pursuant to
the Contractors License La, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec; If.&P.C.]or lits WATER HEATER W/VENT 4.00 L
re"t 11
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION IWATER TREATING EQUIP. 4.00
I hereby affirm that I have u certificate of Consent to self-ins Le, ZONING
or a eertil;cute of Workers Co pe wti n s Dance,or ace Pied ENG.SITE NO.
copy th, o ( •y,B[! .1%5
l'J.J.
PUIILY . ay
O ❑ eHlfied copy be cby u Ish d. FIRE SPRINK ENERGYT-Z4
Z Z ❑ Certified Copy Slc Ili r 'cit iI 'xc ion division. MISC.- REFER TO ORD.
O Applicant V N� V No
~ m PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.V.C.
- CER'I'IIrICt\T.OP SATI EXEMPTION FROM WORKERS'
111 �_ C M PIiNSATTON INSURANCE PLG.CONTR. LIC.NO. PLG. D Y� N� V � N�
CLO (Phis section need not be completed it the permit is for one TOTAL / -
Z hundred dollars IS 1001 or lcssJ
U O 1 enmity (but in the performance of lire work for which this pe" QTY MECHANICAL PERMIT FEE FEE SUMMARY
IL P mit is issued, I shall not employ any person in any manner so as to
Ow become subject to the Worker Compensation Laws of California. BUILDING
Q. Date Applicant ALTER OR ADD TO MECH. 4.00
} to Not-CE*10 APPLICANT': IL alter making this Certificate of Ex-
r ? co ption,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 10)000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that tlm. is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(See MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender; e
Lender',NAddress meNamHEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 0 MSI
•• information is correct. I agree to comply with all city and county PLUMBING v(/
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,1100 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property far inspection purposes.
(We),asrca a save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
mayyin :u�y wa .acprue against said City in co scyuence of the
granting this cit iL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL D oO
Sig lure of Applicant/Contractor Date
I•..',, .b INSPECTOR COPY