5121 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY \�
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
AjIj APPLICATION & PERMIT �� �� x
BU LDI
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME I V QTY. ELECTRIC PERMIT FEE
• I ONE --���
CONTRACTORS CI(o UTLETS-SWITCHES-RECEP 5.00/1,00
NAME
6(jf / o -+, LIC.N.0 j�Q(D44 LIGHTING FIXTURES 5.00/1.00
ADDRESS DDRESS ORS 4_1.(IS PPLIANCES-RESIDENTIAL 4.00
Ar
PHONE n 1-6%y
�/^W PANELS 5,00 DATE OF APPLICATION
ARCHITECTPLA
SIGNS 6,00 N CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ERG SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00,
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
:plofm -} 1 SERVICE CHANGE 10.00 �/5�/ys
woo LICENSED CONTRACTORS DECLARATION 0
a u o I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
at G m ta (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r m z Professions Com� .y��1 my license is in full for'-,',��pyy��f •d. ❑ ❑ ❑ ❑
z 0 o, - License ClassSLI_$S)__U,Number Ul"�& PON
9 r w Dmc Commclor
`a Y BUILDING PERMIT
Or, w e OWNER-BUILDER DECLARATION INFORMATION
A o A U
w firam mMISC.— REFER TO ORD
w g;LL I hereby affirm that 1 exempt from the Contractor LicenseVALUATION
F LL 0 4 law for the following maso..(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city orcounty whichrequiresapermit to construct atleq
¢ ¢ QO improve,demolish,or repair any structure,prior to its issuance)also ELEC.CONTR. LIC.NO, ELEC. I�JsUJ
au
0 LL requires the applicant for such permit to file a signed statement that TOTAL PER IT TO
a w Cr he is licensed pursuant to the provisions of the Contractor's License
Uzi Law(Chapter 9(commencing with Sectiolt 7000)ofDivision 3 ofthe F�rQL'zyQiVC-'l$j
a Business and Professions Code)or that he is exempt thenef o n and QTY. PLUMBING PERMIT FEE
oo the'basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by,any applicant for a permit subjects the applicant Lou civil Penalty ALTER-DRAIN -WATER (EA.) 4.00
1. - of Lou more than Ove hundred dollars($500)J:
❑ 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 Jo the work,and the structure is not -
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREkGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
in improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that be did not build or int- . . .
RES IND CON PB Omer
prove for m,P�Iof xaIc.). INDUSTRIAL WASTE INTER. ' 20.00 RE IN E]❑ 1,as owner of the property,urn exclusively contracting with El El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5+VFB. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Haase Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts torsuch projects with a contrxetods)licensed pursuant LLS
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ tum exempt under Sec. .B.&P.C.for 11,is WATER HEATER W/VENT 4.00
reason
OWDer Dare WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORK ISRS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby al Orm Him I have a certificate of consent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,ora Certified
copy rher•ofl •' 1800,Lab.C.1- =�, R.m11111i
PoI Nr 9 Company Z
N Certified copy is hereby furnished FIRE SPRINK ENERGY T@4
z Z Cl Certified copy is Filed with tire city inspection division.
O Applicant r MISC.- REFER TO ORD. YE] NE Y [:] N4
M y CERI'IFICA'I'Ii 01'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. 4-'
LLI > COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG.
❑ (1 his section need not'be completed if the permit is for one TOTAL Y❑ NY❑ NE]
Z hmtdred dollars 1$100)or less.)
U O 1 certify that in the performance of the work fur which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,1 shall not employ any Person in any manner so as to
U. become subject to the Workers'Compensation I-aws of Culifomiu. M
0 n Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING IP M
} rn NO'T'ICE TO APPLICANT: If,after making this Certificate of I>x- W
Z cmptlon,you should become subject to the Workeri Compcnsutiun APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit slid)be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3A0 41 qd
CONSTRUCr1ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE Q
I hereby ance that them is a construction nut is
agency Rr EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this punnit N issued(Sec MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50' ELECTRIC
Lender's Address
I Certify that I have read Deis application and state that the above VENTILATION FAN (SINGLE)- 3.00
information is CIIrTLCI. I agree to comply with all city and county PLUMBING
ordinances and stain laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 j
hereby authori7e representatives of this city to enter upon (lie BOILER-COMP (Over 100,000 BTUI SEE FEE SCH: MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way Meru, against said City in consequence of the
gra I g f this Pe it. MECH.CONT. LIC.NO. ' MECH. 4
_ TorAl. TOTAL
Sign Lure of Applicant/Contractor Date
INSPECTOR COPY