3225 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FI N PERMI R
)r1l,LD,NG APPLICATION & ALIT 3225
ADDRESS e.0 PC`f<TLVc
00() WOL,PE RD, BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
\, OWNER'S PLAN CHECK VALIDATION
oG NAME 25.'/-700h OTY.
�E-,,���.�•_p/1e,KhKO r ELECTRIC PERMIT FEE ! S r�S^
PRONE -C d
cua
CONTRACTOR TOR's o3 OUTLETS-SWITCHES-RECEP 5.00/1.00 v
NAME
LIC.NO. LIGHTING FIXTURES 6.00/1.00
CONTRAc Rs
ADDRES APPLIANCES-RESIDENTIAL 4.00
_ FRONS PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE .N
OR SIGNS 6.00 I
ENGINEER LIC,c.No. SIGNS TRANS. 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER 08 POLE INS. 15.00
ADDDRESS /D
ADRPPLIESS r$ MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION
¢u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a t (commencing with Section 7000)of Division 3 of the Business and BLDG. LECT. PLG. MECH. -
r y i Professions Code,and my license is in full force and effect. El 1:1 [I]
0 i m w . License Class Lic.Number
Dale Contractor
< r BUILDING PERMIT
¢ ¢o i OWNER-BUILDER D17CLARATION INFORMATION
S.,
; H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a. O¢ Law 1.r the f011owIn reason.(Sec.7031.$,Businessend Professions VALUATION $/FT.
Z;N se g PERMIT ISSUANCE 6.00 r �-�
> Code:Any City Orirounly which requires a permit t0 construct,alter, OG
¢ ¢ ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.N0. ELEC. �Fr U `3 U�0"
A wDLL requires the applicant for such permit LO file a signed Statement that TOTAL //VL.�_ PERMIT TO
$ m he is licensed 9(coPursuant to the provisions of the ) fDiiaContractor's License
H i> Law(Chapterand
Processions(commencingwithor thal lie 7000)of t therefool the �IQ/
4 o
Business and Professions Code)or Thal be is exempt therefrom and OTY. PLUMBING PERMIT FEE
IE H ore the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CON TR.
A. by any more tha fore permit subjedsthe applicant toacivil penalty ALTER-DRAIN IEA.) 4.00 �d/�
of not more than five hundred doIproperty,
0(my em): idiot/
❑ I,as owner at the properly,or my employees with wages as BACK F LOW PROTECT. DEV ICE 2.00 OCC.GROUP RES. NITS
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 docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himselforof ugh intended
owl]employees,for sale.
If.ed however.at the
improve- GAS-EA.SYSTEM-1 4,00
mems are Not intended or offered for sale.If,however,the building
't or improvement is sold withinone 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 im. RES MD CON PB Otbar
Prov ar purpose of'air
I INDUSTRIALWAST•E INTER. 20.00 RE IN ❑
I,as owner of the property,am exclusively contracting with
if is contructors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and Professions Code:The Can trit
aor's License Law Jaen not apply �/�� �/�
to tracts o of properly who builds tr improves need pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 1.00 OA/ r s�'�(A�lr
contracts ctur'a h projects with a contractods)licensed pursuam m
the Contractor's License Luw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea_7 ,BAP.C.for this WATER HEATER W/VENT 4.00
reason
X Date IPIDA Owner WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent l0 self-insure.
or a certificate of Workers'Compensation Insurance,or a cerlificd ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGYQ T$4 -
Z Z ❑ Certified copy is filed with the city inspection division. ,,\LR1L11
O Applicant MISC.- REFER TO ORD. y Y
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE -
W � COAIPF.NSAT'ION INSURANCE PLG.CONTR. LIC.NO, PLc.
= Z (This section need not be complefud if the Permit is for one TOTAL v❑ -� U nisi
hundred dollars($100)or less.)
U O 1 certify that in the performance or the work for which Ibis per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any mannerso as m
Ow become subject to the Workers'Compensation Laws of CulifoolW.
C. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING Ov
>_ N NOTICE TO APPLICANT. If,after making this Certificate of Ex. -
H 2 eruption,you should became subject to the Workers'Compensation APPLIANCE' 4.00 PLAN CHECK
provisions of the Labor 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
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 1OPMC.FM.) 5.00 SEISMIC FEE a/O
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Performance of the work for 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
(certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
Ordinances1 n carred. I agree to comply with all oily and county PLUMBING
ordinances and state laws relating to comply
will
construction,co and BOILER-COMP(3 H.P.or 100,000 B.T.U.Y 4.00
hereby authoriie 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 harniless the City of MISC.- REFER TO ORD.
` Cupertino against Iiubili'es,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX '
may in y way ac' against said City in consequence of the
I Is MECH.CONT, LIC.NO. MECH.
�( F� sir �&AW 7, TOTAL TOTAL p(, /0
Signature ofA icant/Contractor Date
- OFFICE COPY