10729 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 0729
O/o5 RI e
OWrvERS PLAN CHECK VALIDATION
"" CITY. ELECTRIC PERMIT FEE
' PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1,00
NAME
T L) LIC.NO. b -1 LIGHTING FIXTURES 10,00/1.00
CONTRACTORS pp PPLIANCES-RESIDENTIAL 4.00
ADDRESS I-Ibg-q hOfJERS -
S PHONE++3b-OI O PANELS 10.00 DATE OF APPLICATION
ARCHITECT q ;Ik2- PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR CI
ENGINEER
LIC.rvo. SIGNS TRANS. 3.00
ARCH.OR ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ziv EMP.METER OR POLE INS. 20.00 )
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 q
D O o LICENSED CONTRACTORS DECLARATION (//!�r/"[�(
G v w I hereby affum That I am Bcensed under provisions o(Chapter 9 ISSUANC DATE
Z, d (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r D i Professions Cody,ay{I y license is in full for en c fie
z o�2 - Licen Class t- O Lic.Number - ❑ ❑ ❑ ❑
2 N H w9 Date Contractor
a y2 " BUILDING PERMIT
¢ ¢ ia OWNER-BUILDER'DECLARATION INFORMATION
LcI w _ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER,TO ORD
VALUATION g/FT.
u o Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - 1000
- � � Code:Any city or county which requires a permit to construct,alter,
2 ¢ ¢ improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
O.LL requires the applicant for such pennit to file a signed statement that TOTAL PERMITTO
whe is licensed Pursuant to the provisions of the Contractor's License pppp
H z a Law(Chapter 9(commencingwith Section 7000)of Division 3 offle
4 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by Any applicant for a permit subjects the apple...ituacivil Penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not moa than five hundred d011aa(S50O).): ..
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will On the work,and She structure is not
intended or offered for.[a (Sea 7044, Business and Prufcssions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Q-
Iry
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves therton,and who does such work F IXTUR ES-PER TRAP 5.00 BO.FT.FLOOR AREA TOTAL ACREAGE
-� himself or through her own employees Provided that such improve- GAS
or
6.00
ments are not intended or oftered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS- SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have.the burden of Proving that he did not build or Im- - RES IND CON PB alar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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. 6.00 ASSESSORS PARCEL NO.
and.Professions Code:The Contactor's 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 conlractons)licensed pursuant toft/10.00
the Contractor's License Law. SEWER-SANITARY-STD TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.ILr this WATER HEATER W/VENT 6.00
reason -
Owner Date - WATER SYSTEM I _ .00 ACC.DATE ACC.FILE NO.
.I WORK CRS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby from that I have a certificate of consent to ulGinsure, I 0 tupelfillaZONING ENG.SITE N0.
or a cenifirs a of Workers'Compensation Insurance,or certified
coPcrc f( c.3$0),Lab.C. C&�,
PohcyN Corn ony�
O ❑ ertifie copy is herchy Nnakld. FIRESPRINK ENERGY T]4
Z = Csrtifmp��opy 6 fit�pw 4ill city inspection division.
O Apphen, i'/�L.S�=� MISC.- REFER TO ORD. Y'❑ N❑ Y ❑ N❑
PI
Q T CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 Q u FLOOD ZONE A.L.0 c.
LU > COMPENSATION INSURANCE PLG.CDNTR. LIC.NO,. PLG. Y❑ N❑ V'❑ N❑
EL D (This section need not be completed if the permit Is for'onc TOTAL
::) Z hundred dollars($100)or less.)
U O 1'certily that in the perfurmance of the work for which this per. CITY MECHANICAL PERMIT FEE FEE SUMMARY
L, I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICB TO APPLICANT: If,after making this Certificare of Ex--
LZ emptiun,you should become subject to the Warkeri Co rmumadam APPLIANCE 5.00 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=CF.M,) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfomrfance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nam
der'sAdd,
e HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC -
LeaAddress
I certify that is
read this to comply
and state that the above VENTILATION FAN (SINGLE) 4.00 as
information E correct.laws
reg to comply with all city olid county PLUMBING p(y
ordinances and state laws relafing to building construction, and BOILER--OOfB(3 H.P.or 100,000 ELT.U.) 6.00
146 hereby authorize representatives of this city to enter upon the
pBOILER-COMP (Over 100,00OBTU)BEE FEE SCH. MECHANICAL
above-mentioned rapeRy 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 10,00 CONST.TAX
may in any way accrue against said City in consequence of the
ga gof this Penni . / MECH.CONT. LIC.NO. MECH.
41/e. •.&k_ /I/ Im
TOTAL TOTAL
Signature of App na [/Contractor DID, _
OFFICE COPY .