7155 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
AAPPLICATION & PERMIT
ADDRESS
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 55
71
AlNEmS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
' PNONEVq
rvT ACT#, UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
I� 'Itnroe Ic.ND. LIGHTING FIXTURES 5.00/1.00
CODNADDRESS
TRACTOR s PPLIANCES-RESIDENTIAL 4.00
�,[ ✓�PHONE 'b PANELS 5.00 DATE OF APPLICATION
ARCHOECTSIGNS 6OO PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.EDR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDSS z.v TEMP.METER OR POLE INS. 15.00 4.
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSED CONI TACTORS DECLARATION / J
a v U I herchy uffnn that I am licensed under pnreisions of Chapter 9 ISSUANCE DATE
w (Connnen,Ing with Section 7000)of Division 3 of the Business and BLDG.
ProfessionLs Code ml hii aELECT. PLG. MECH.
,e is in full for' eD•' �. ❑
i 0,.,- License Claus- Lie.Number ❑ ❑
O F w )at, � _Cunlmclnr
s /2Ld _ BUILDING PERMIT
1 ¢
at,
a OWNER-POILDER DECLARATION INFORMATION
3 a. r I hereby uflinn that I an,exempt frons the Contractor's Licerric MISC.- REFER TO ORD
VALUATION $/FT.
"s .. o¢
Law for the following reason.ISec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
+� - Code:Any city or county which requiresp purinh toconstuaLaltcq
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
6
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
)w m he is licensed pursuant to tire Pnrvisinnx ol'the Contractor's License }] p
'x� HZQ
Law.Whapler9(commencing with Sect ion 7000)ofUivision 3 of the
4 0 Business and Professions Code)or that Ire is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ ro the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a ;m by any applicant for a Permit subjects the applicant ton civil penalty
ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($5001.):
I
❑ I,as Owner of the property,or my employees will,wagesa, BACK FLOW PROTECT.DEVICE 2.00
their sole Compensation,will do the work,and lite structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'rhe Contractor's License Law docs not apply to an owner of 5
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP4.00 SO.FT.FL00R'AREA TOTAL ACREAGE
himself or tm
hrough his own employees, ro
yees,pvided that such improve-
mintsarc not intended oroDered for sale.If,Imwever,lire building GAS-EA.SYSTEM-11 NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner GASEA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ire- - RES IND CON PB Ome,
prove for purpose W sale.). INDUSTRIAL WASTE INTER. 20.00
D 1,as owner of that property,am exclusively contracting with ❑ 'ED ❑ ❑ ❑
ireenscd contractors to constructthe project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profession.Code:The Comractor%License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
lire Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,BAP.C.for.this WA RHEATER W/VENT 4.0
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKERS'CO,MPENSA1'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsenl to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ate itifia
copy thereof(Sec.3800,LuhC.l.
Policy No. Cam puny
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z z/ ❑ Certified copy is tiled with the city inspection division. MISC.- 4REFER TO ORD.
Q/. APPlicanl Y ❑ N❑ Y ❑ No
CCN CER"I'u'ICA'fE OF EXEMPT TON 17 ROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.11.C.
W > CO)IPENSATION INSURANCE P .CDNTR. ' LIC.rv0. PLG.
CL ❑ 1'1'his sacu n need not be completed it the permit is fur one Aa J!_ �/4'� TOTAL Y❑ N❑ Y ❑ N❑
Z) Z ho l uodollars(5100)or loss.)
U O I earth, that in the pa,00 nan.of the work lin which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F .nit is issued, I shill not employ any person in any manner sr as to
U hocomc sub',al to Ih• orkcri COytpcns:o inn Lnws of Calif 'd.
ED Darn_ PrIheantAi/O SM✓ �Ls ALTER OR ADD TO MECH. 4.00 BUILDING
} w NO TI 'li ' APPLICANT: Il,__alter making this Ccrtifiwtc of Ex-
FO Z eniption,you Should beconm subject to the Wotkers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Corte, you nwst forthwith comply with FEE
U v¢h provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'FRUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance ol'tire work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NameH EATI NG LIN IT(OVER 100,000 B.T.U.)7.50
Lender's.AdddressELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING 3 Q
urdinunces and state laws relating to building construction, and BOILER-COMPQ H.P.Or 100,0008.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 properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the Cityof MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting Of this permit MECH.CONT. LIC.NO. MECH
e & '
d
&/� TOTAL TOTAL
Signatre of Applicant/Contracuft Data
INSPECTOR COPY