0454 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PE Y
•r/•I.�' BUILDING PROJECT I DENTI FIC PERMIT NUMBER
BUILDING �pQ /� BUILDING APPLICATION & P T 044
ori -ELECTRICAL-PLUMBING -MECHANICAL
- - PLAN CHECK VALIDATION
OWNER'S
yrNi� 'AI 996 �y Y• ELECTRIC PERMIT FEE
NAME CONTRACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
uc.NO,
LIGHTING FIXTURES 5.00/1.00 I,I,'
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 V
• ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.QQ PLAN CPTET7 P.C.NO. .,
OR
ENGINEER ucNO. SIGNS TRANS. `Nft 3.00
.
AR CH.OR ENG. S,QQ - PERMIT VALIDATION
ADDRESS SPECIAL CI
- ZIP EMP.METER OR PO 15.00
APPLI MOTORS SEE FEE SCH.
ADDRESS ESS
SERVICE CHANGE 10.00
SE
o LICENSED CONTRACTORS DECLARATION ��
a uH ISSUANCE DATE
o 1 hereby affirm that I am licensed under provisions of Chapter 9
y a H (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
w z Professions Code,and my license is in full force and effect ❑
z o w - License Class Lic.Number
o z Date Contractor
N F
BUILDING PERMIT
¢ ¢o w OWNER-BUILDER DECLARATION - INFORMATION
w3 ¢y I hereby affirm that I am exempt from the Contractor's License MISC.- REF ER,TO ORD - _ VALUATION S/FT.
Fuc J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 •1
Code:Any city orcounly which requires a permit to construct,alter, PLED.GONTR. LIQ NO. O•
SE a a improve,demolish,or repair any structure,prior to its issuance,also TOTAL
O ¢ requires the applicant for such permit to file a signed statement that TOTAL ( PERMIT TO_
is $w he is licensed pursuant to the provisions of the Contractor's License �/J,_�I _, J
H z:> Law(Chapter 9(commencingwith Section 7000)Of Division 3 of the („�CLP�R-�-'r�—
er Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
S O ffTSTORITYPE CONSTR.
m.r the basis for[he alleged exemption.Any violation ofSection 703ltyage by any applicant forapennit subjects the applicanttoacivil penaltyALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 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,AREACOND. 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 FIXTURES-PER TRAP 4,110 TOTALACREAGEmenta arc otintendehrough Ownemredforssle.If,ed that however,th improve-, GAS-EA.SVSTEM-11NC.40UTLETS 4.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SVSTEM-OV ER 4(EA.) 1.00 NG uSE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose ofaille). INDUSTRIAL WASTE INTER. 2400 F] [:]❑ 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. 5.00 ASSESSORS PARCEL NO.
and Professions Code'.The Contractor's License Law dues not apply
4 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under See,.,B&P C.for this . WATER HEATER W/VENT 4.00 -
reason
Date Owner WATER SVSTEM 4.00 ACC.DATE ACC.FILE NO:
•,2,,,,,. ggR ER F.NS�, L.AR A WATER TREATING EQUIP, 4,00
1 hereby affirm that I have acne o Sclf-insure, ZONING ENG,SITE NO.
Or a certificate of Workers'Compensation Insurance,or a cerci fled
copy thereof(Sec.3800,Lab C.). '
Policy No. Company -
Q ❑ Certified copy is hereby furnished.' FIRE SPRINK ENERGY T24 t
Z Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD. Y N� y ❑ N[0
Applicant
H v0-i PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 c.
X - CERTIFICATE OF EXEMPTION FROM WORKERS'
LU :s, COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y NI] Y❑ NE]
d (This section need not be completed if the permit is for one - TOTAL
D Z hundred dollars 1$100)Or less) - FEE SUMMARY
() O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE
LL F mit is issued,I all not employ any,person in any manner so as to
OWbecome subject to the Workers'Compensation Laws of California. BUILDING 3Y �
Date Applicant ALTER OR ADD TO MECH. 4.00
} w "NOTICE TO APPLICANT: If,after making this Certificate of Cx- 4.00 PLAN CHECK
F Z emption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code, you must forthwith comply with FEE air,U 3
() such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE „N
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00
3097,Civ.C.).
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC �/r Q•-Q
Lender's Address - -
I SItHify that l have read this application and ,are that the above VENTILATION FAN (SINGLE) 3.00 PLUMBING
information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 _
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)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.
p Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may i ny, way accrue ag s[ sof City in consequence of the eft M-1
an of this rm"f. MECH.CONT. LIC.NO. MECH. - / '-
b TOTAL TOTAL
ign are o APpli-cantrContractor
I .. OFFICE COPY