4304 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL_ POINT PEN ONLY
BU I LDINGRROJECT I DENTIFICATI ON
/AO
- PERMIT-NUMBER
APPLICABGIEOINc TION & PERMIT
S .44 LU BUILDING - AL-PLUMBING-MECHANICAL 4
304
DANE 'B PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
P�o
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
s!Y E AJ c.N LIGHTING FIXTURES 5.00/1.00
POORRess Togs APPLIANCES-RESIDENTIAL 4.00
offI6 aA?P/COT .1011C PHON 7- J _PANELS. 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR SIGNS 6.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00 ADDRRESS
ASS SPECIAL CIRCUIT 5.00 -] PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 L
noolCss TS MOTORS SEE FEESCH.
SERVICE CHANGE PAM 10.00
O O LICENSED CON"TRACTORS DECLARATION al /
K u 1 hereby affirm that I am licensed under provisions of Chapter 9
2 w ISSUANCE DATE
m Q H (commencing with Section 700e)i of Division 3 oyfIthe Business and BLDG. ELECT. PLG. MECH.
H H z Professions Cod �n I ty license is in full f--; J ❑ ❑ ❑
0 o v, - Linens las Lic.Number j J
FH H Date�Contcmor
¢ rt ¢ a OWNER-BUILDER DECLARATION
BUILDING PERMIT
wo a U INFORMATION
; u y Iherebyfth collo that I om exempt (than the Contractor's License MISC.- REFER TO ORD
wOj Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 6.00
,A � Cade:Any city or county which requires apermit toconstruct,alter.
ar Ic i Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / Q=
O ¢ requires the applicant for such permit to file a signed statement that �•s TOTAL
¢ is y fie is licensed pursuant to the provisions of the Contractors License PERMIT TO
Hz>
Law(Chapter 9(commencing with Section 7000)ofDivision 3ofthe use
f 4 o Business and Professions Code)or Oct he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ f pN the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a 3 � by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollars($500).):
ALTER-DRAIN VENT-WATER (EA.14.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 2.00
their sole compensation,will do the work,and the structure is not occ.cgouP RES.UNITS
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 of
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 sG.FT FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees,provided that such improve- .
or nts impro"menn intended or within
onefor
yeasale.l however.the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of lie did ion,Ore owner-
builderrim-
will have the burden of proving mm he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of the.). RESINDUSTRIAL WASTE INTER. 20.00 ❑ I❑ ❑ry Ell❑ Other❑
❑ d as owner of the property,am project
. 7044,ling with
licensed contractors to construct the project La does Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractors License Law does not apply
to tr owner of h projey who builds or improves rased p,and who LAWN SPRINKLERS-OVER 5(EA.) 7,00
contracts far such License
ee is with a contractoR s)licensed pursumtl to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200h/8.00 TRACT NO. PARCEL No.
❑ I am exempt under Sec. li.&I'.C.iia mit WATER HEATER W/VENT 4.00
reason
Date - Owner WATER SYSTEM 4.00 ACC,DATE ACG FILE NO.
WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate of consenl to tel Ginsure. -or a certificate of Workers'Compensation Insurance or a certified ZONING ENG.SITE NO.
copy thereuf(Sec.3800,Lab.C.).
P li No. Company
�JCertilied co yis heroby tarnished' FIRE BPRINK ENERGYT 24
Z Z ❑ Cerl it ied ry filed m the ci inspection Division.
H p Applicant _ REFER TO ORD, Y ❑ N Y ❑ N�
y CI?R ICA'TIi OP EXITMI'1'10 FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL.U.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLD.
d O tThis section need not be completed if the permit is for one
TOTAL v N v N
Z hundred dollars(S 100)or less)
C.1 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 us to
O w become subject to the Workers'Compensation Laws of California.
t Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
>- N NOTICE TO APPLICANT: If,after making this Certificate of Es-
? entption,you should become subject to the Workeri Compensution APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Codc, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IOMC.F.M.1 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCTI 2,00
the performance of the work for which this
permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state thm the above VENTILATION FAN (SINGLE) 3.00
. ordinances ncorrectlagreetocomplywith all[city and couJly BOILER-COM P(3 H.P.or100,000B.T.U.) 4.00 PLUMBING
ordinances end tam laws relating to building l attraction. rad
hereby authorize representatives of this city to to upon the BOILER-COMP Over 100.000 BTU)BEE FEE SCH.
above-mentioned property for inspection Purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TOORD.
Cupertino IS 'nst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3,00 CONST.TAX
army in an iy ue against said City In consequence of tile -
granting is lip
t �/ y MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
.lure u ppfican1JCoCtraCtorZ Data
OFFICE COPY '