0819 PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT OM ONLY
ex
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
JF[AUILDING APPLICATION & PERMIT 0819(�
00 1 a7
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
NEIL'S PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE
NOMTRACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
C ` ` uC.No. LIGHTING FIXTURES 5.00/1.00
.oNFRACTOR's 7 APPLIANCES-RESIDENTIAL 4.00
ADDRESS
-PHONE PANELS 5.00 OATEOF APPLICATION
ARCHITECT LIC.
6.00 PLAN CHECK FEE P.C.NO.
0R
ENGINEER '
' c.No. SIGNS TRANS: 3.00
ARCH EOR END SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
AS
SERVICE CHANGE 10.00 !/
o
0 0
� O O LICENSED CON'1'RAC'1'OHS DEL'LARA'fION".
a v u 1 hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
a wit(commencing with Section 7000)of Division 3 of.the Business anI nor A IA
BLDG. ELECT. PLG. MECH.
m i Professions Code 1 my license is in toll In, 54tH .-/ ❑ ❑ O
z: o w - License a_ss _ Lie Number•�"7 _l
9 F.D Uat1 Contractor /�, JULO t(�8t
r J lJL 4 r BUILDING PERMIT
¢ w OWNER-BUILDER DECLARATION INFORMATION
w3 LL H 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION 5/FT.
o j Law for the following reason.(Sec.7031,5,Business and Professions PERMIT ISSU 6.00
IA0 Code:Any city orcounty which requiresa permit to construct.alter, � _d IP
ce Q Improve,demolish,or repair any structure,prior l0 its Issuance,also ELEC.CONTR. LIC.NO.
Q Q ELEC. /
- DLL requires the applicant for such permit to file a signed slulement that TOTAL PERMIT TO
a w he is licensed pursuant to lire provisions of the Contractor's License `
L, re va Law(Chapter 9(commencingwitlr Section 7000)of Division 3 ofthe • P/k_ib/.�,� � �
- a Business and Professions Code)or that he is exempt tberefrnm and OTV. PLUMBING PERMIT FEE
fe basis for the alleged e%empti.n.Any violation of Section 7031.5
D the STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER'(EA.) 4.00
of not more than five hundred dollars(S500F)
❑ 1,as owner of the property,or my mnplayces with wages as - BACK F LOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the ptruchuc Is act
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code The Contractors License Law does not apply to an owner of
properly who builds or improves thereon,:std who docs such work FIXTURES-PER TRAP ' . 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
mentslCte through his own cmfors,provided what such improve-
mmself r ,,t intended or offered Ro,,r, ,,e.,Ccd thin rLhebuilding GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or int-
provefor purpose ol'sale.). - INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
❑ I,a of the property,am exclusively contracting with El El ❑_ El El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contract,,,',Lirenw Law does nor apply
to an owner
of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 -
contmcts for such projects with a coNmet.00 licensed pursuant to
Ilio Contractor's Liconsc Lxw, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ivor exempt under Sec. ',It.&P,C.for this WATER.HEATER W/VENT 4.00
11.1011
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORSE RS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4-00
' 1 hereby affirm that I have a certificate of consent to self"insure. ZONING -
or u certificate of Workers'Compensation Insomorl,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
O :Pol¢'No. Company '
Certilicd copy st meby furnished. FIRE SPRINK ENERGY 24
❑ Cert if�pd 's-f hy-,,����ly rr tmu division.
" z p gpplicam' ^ _L MISC.- _ REFER TO ORD. y ❑ N❑ Y ❑ No
CC L4 CER'I'IFICATIi OFHXEMPI''I✓ONPk(NWORKERS' PERMIT ISSUANCE 6.00FLooD ZONE A.L.0 C.
LU > COMPENSATION INSURANCE PLG.CONTR. , LIC.No. - - PLG:'
C m
0 this section need not be completed if the permit one is lot u TOTAL Y❑ N❑ Y ❑ No
'Z) Z hundred dollmx(SIOO)or lass.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any person in an)'nomrer w as to
U become subject to the Workers'Corepensution Laws of Culitc ia. �p
ED Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING '�
} to NOTICE'f0 APPLICANT: If,atter making this Certificate of Ex
x-
F Z emplion,you should become subject to the Worker Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Cabo, Code. you must forthwith comply with FEE ��••'
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY .s AIR HANDLING UNIT(OVER 10XWC.F.M.) 5.00 SEISMIC FEE ,�7J
I hereby affirm that there is u construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.1 4.00 MICROFILM
3097,Ci,,CJ.
Lemma 1 NameHEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address t ELECTRIC
I cattily that I force read this application and sate that the also�c VENTILATION FAN (SINGLE) 3.00
information is correct 1 agree IN comply with III city:cod county PLUMBING
ordinances and state laws relating to budding construction, Ind BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize represcntm,ex of this city to enter upon the BOILER-COMP IOve,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We)'ogre to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
CupertinaF Est liabilities,judgments, costs and expenses which - CONST.TAX
in. 4 way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 -
g' h t•I t. MECH.CONL LIC.NO. MECH. �
TOTAL �� 5
Signature App oritract,V I Date
OFFICE COPY '