8304 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
D .F. .fJBUILDING - ELECTRICAL-PLUMBING-MECHANICAL8304 1,
OWNS 'S PLAN CHECK VALIDATION
NAME CITY, ELECTRIC PERMIT / FEE
Q I- r PHONE -
NAMERACTOR's UTLETS-SWITCHES-RECEP i .00
Lv�kSJ ELFC , LIC,N13ZIOZ.00 LIGHTING FIXTURES 10.00/1.06
CONTRACTOR'S
ADDRESS �„ PPUANCES-RESIDENTIAL 4.00
-zn/, Cln1TRA1_ PHONC^ 7q- /U/ PANELS 10.00 DATE OF.APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR END. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zm rEMP.MET OR POLE INS. 20.00 'E /
APPLICANT'S 1� I/OVtr
ADDRESS MOTO SEE qEE SCH.
: S ICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION EMP.POL 30.00
a U 1 hereby affirm that am licensed under provisions of Chapter 9 X k VISSUANCE DATE
H <y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect.
Z, i w o License Class Lic.Number F ,
,A F Date Contractor 1 ❑
Q y E
¢ ¢ w ¢ OWNER-BUILDER DECLARATION BUI DING PERMIT
w 3 n m 1 hereby affirm that 1 am exempt from the Contractor's Lice e
M C. REFER TO ORD IMFORMATION
FLLoa Law for the following reason.(Sec.7031.5.Business and Pro fessi as PERMIT I CE / VALUATION
Pw >f Code:Any city or county which re9uiona permit locmutruct,alar, 1
ca ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,a 0 ELEC.CONTR. LIC.NO. ELEC.
LaD ¢ requires the applicant for such permit to file a signed statement th t TOTAL PERMrt TO
mm he is licensed pursuant to the provisions of the Contractor's Licen.
>
Law(Chapter 9(cmumencing with Section 7000)Of Division 3o lthe
- 5 i o Business and Professions Code)or that Im is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F m the basis for lire alleged exemption.Any violation ol'Seclion 7031.5 5 I T PE CO STR.
d3 � by any applicant for a permit subjects the applicant to a civil penalty
ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five humdmd dollars($500).):
❑ I,as owner of the property,Or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 0 u RES.UNITS
theirsole compensation,will do the work,and the structure is not
intended or Offered for sale (Sec. 7044, Businees and ProfessionsDRAINS-FLOORROOFAR EA,CON D. 5.00
Code:ThoOf , ,
Tire Contractor's License Law does not apply to owner
property who builds or improves lherron,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA r qc EAGE
• nd
himself re through his own employees,provided ho than such ingtovo-
or unprre anent intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden OI'proving that hedid not build Or iin- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND Pa Omer
O 1,as owner of the property,an . .
]exclusively contracting with ❑ 0 9 0
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORPARCEL NO.
and Professions Code:The Contractor.S Liceaw Law does not apply
to an owner at'property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with n contraclonsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCELNO.
❑ I am exempt under Sec. ,B.&1'.C.for fills WATER HEATER W/VENT 6.00
reason
Owner Hate WATER SYSTEM 5.00 -yACC.DATE ACO.FILE NO.
WORK F-RS'COMPI:NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm thus 1 have.crnific.tc o1-consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lab.C.).
Policy No. Company2 c 5c 5 1. 10.410x-1 q_
O pp Certified copy is hereby furnish FIRE SPRINK ENERGY T-74
Z Z d�ferlified oyy is fled wi0 the 1y Inspection division.
F- O' pplicaM-C-�.r�ss- MISC.- REFER TO ORD. v� N� v � NE]
LU A
CC
w 'CERTIFI TE OF EXI_i, pl'IONFRWORKERS
OM ' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
W COMPENSATIONI NSURANCE PLG.CONTR. LIC.No, pLG.
CL O (This section need not be completed if the pe nn it is ter one TOTAL Y❑ NY ❑ NEI
Z hundred dollars(S100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Ow become subject to lire Workers'Compensation Laws of California.
y Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
�- W NOTIC17 'TO APPLICANT: It,after making this Certificate of Ex-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must nothwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOXWC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work lit which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC -�
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives forms of this city to enter upon theaboveBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
mauthored properly tativ spof this
ion Purposes.to.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in con sequwnec Of"
grantingoflhis permit./ Mo
MECH.CONT. LIC.NO. MECH. /
/ i TOTAL TOTAL
Signal re of Apph nt/Commc[or Date
INSPECTOR COPY