3754 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI. POINT PEN ONLY
BOJLDI NG PROJECT I,DENT[FI CATION PERMIT NUMBER
„to,D'uG APPLICATION & PERMIT l'�1
'\ _ REss Q1�/ BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 37" 4
f
OWNER'S .PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE
NE I
AME An S '
AME OUTLETS-SWITCHES-RECEP 5.00/1.00 -
- OAIWAZALIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR ESS c
An - PPLIANCES-RESIDENTIAL 4.00
CO _
PHONE PANELS 5.00 - 'DATE OF APPLICATION '
ARCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR -
ENGINEER
LIC.No. SIGNS TRANS. 3.00 -
ARC ORERG: PERMIT VALIDATION '
ADDRESS SPECIAL CIRCUIT. - 5.00
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT
ADDRESS MOTORS SEE FEE SCH. -
i/ SERVICE CHANGEPAI
10.00
F O o LICENSED CONTRACTORS DE;CLARAI'ION f[
¢U w I hereby affirm Ilod I am licensed under provisions of Chapter 9 - - - ISSUANCE DAT 't
w 4 (co urr,ocin with Section 7000)or Division 3 Of the Business and -
¢ y g 'BLDG_ ELECT. PL6! MECH,
H z Cited-
2
Code,and my license is in full force and effect ❑ ❑ ❑
0 m.p License Cl
o Lie.Number
. H m J Date - Contractor
¢ m s City Of CupertinoBUILDING PERMIT
re le a " OWNER-BUILDER DECLARA'T'ION
A ao c v INFORMATION
w ; N I hereby affirm fiat I am exempt from the Contractors License MISC.— REFER TO ORD
u. o j Law for the followin reason.(Sec.703 t.5,Buslnessand rrofcssiuns VALUATION $/FT.
g PERMIT ISSUANCE '6.00
Code:.Any city or county which requires a permit to construct,alter, - '
rc ¢¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEGCONTR. LIC.ND. ELEC
, tenures the appli"m for Such permit t0 fd...lgnld Statement that •r TOTAL PERMIT TO
n w he is licensed pursuant 10 the provisions of the Contractor's License -L4e—r G
r z i Law(Chapter 9(commencin'g with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that htherefrom
e is exempt and OTY. PLUMBING PERMIT FEE
fe =$ the basis for the alleged exemption.Any violation of Section 7031.5 i STORIES TYPE CONSTR.
by any applicant for a permit subjects lire applicant toacivil penalty ALTER-DRAINSt VENT-WATER '
of not more than five hundred dollursfS5001.L. .Cl I,as owner of the property Or my employees will,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'
Code:The Contractor's License Law does not apply to an owner 01'
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-
11[1 'tsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
rpravement is sold within one year of completion; the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
uildcr will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner Of the property,am exclusively contrueling with ❑ , ❑ ❑ ❑ ❑
licensed contractors m comstrucl the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nor 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 contractods)licensed pursuant to
the Contractor',License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCELNO.
❑ I';vn excerpt under sec. ,B:Bd'.�. utfhls WATER HEATER W/VENT 4.00 I•
reason Own l
'Date, WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. - 4.00
. I hereby aRirm that I have a certificate of consent msell'-insure -
or a certificate of Workers'Compensation Insurance,to a curt ifieJ — ZONING ENO.SITE NO.
'copy thereoffSec.3800,Lab,C.). ,
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY L24
Z ❑ Certified copy is riled with the city inspection division. MISC.- REFER TO ORD.
O Applicant I Y ❑ NE] Y.❑t 'N[]CC w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL.U.C.
L COMPENSATION INSUIZANC17 PLG.CONTR. ' LIC.NO: PLG.
- CL Z (This section need not'be completed if the permit is for one TOTAL YE] , N❑ Y ❑ NE]N
hundred dollars IS 100)or less.)
'L) O , I certify that in (lie performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F- ' mil is issued,I shall not employ any person many manner so as to
O w becmric subject to the Workers'Compensation Laws of California.
Is. Dam Applicant ALTER OR ADD TO MECH. 4000 BUILDING .
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
p,UvOioms of the I.nbar'Codc, you must forthwith unh only witFEE
U 'such prnvisinns cur this permit shall he deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) ' 3.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10=1C.FM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the workdor which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
'Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree t0 comply with all city and county - PLUMBING
A"- < and:sfale laws,reldting to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
r Yuthoriae representatives of this city to enter upon the
ve-Ineatloned property for inspection purposes. BOILER-COMP IOYa(100,000 BTU)SEE FEE SCH. . MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
- +ma,y
ertino against liabilities,judgments, costs and expenses which CONST.TAX
y in anwaynccrue against said City in coucnuence of the .PERMIT ISSUANCE 3.00
' this permit MECH.CONT. LIC.NO. MECH.
`� (z9I� GTALTOTAL
f Applicanl/Contractor )ate
OFFICE COPY.