3879 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
SoLUING APPLICATION & PERMIT ( 3879
X ADDRESS I
_ BUILDING-ELECTRICAL-PLUMBING -MECHANICA
NEe'S PLAN CHECK VALIDATION
NAME 93 QTY. ELECTRIC PERMIT FEE
3- q PHONE�s s
NAAME CONAcroR$ UTLETS-SWITCHES-RECEP 5.00/1.00
Lie.N-0 ILIGHTING FIXTURES 5.00/1.00
ADDRESS AACDroRs PPLIANCES-RESIDENTIAL 4.00
CONTE
PHONE PANELS 5.00 DATE OF APPLICATION
ARRC HRECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDREOSS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP EMP. METER OR POLE INS. 15.00
As
ADDRESS MOTORS SEE FEE SCH.
DRESS E55
SERVICE CHANGE 10.00
0 o O LICENSED CONTRACTORS DECLARATION Gxf4ex t,.t Pro 7"�'Y
a u w `1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a N (commencing with Section 7000)of Division 3 s(tht Iiusines'and LBL .[ T� PLG. MECH.
F w z Professions Code,and my license is in full force and effect. [ O ❑ ❑
z o m - License Class Lie.Number ¢„ [.H7 if$
0 y r w Date Contractor THA 7'0 2 /N
c y s � A u l S - to B r a Lu.x.t�z .i a (s 1{ G P E R M I7
¢ ¢w vt OWNF.RBUILDER DECLARATION CI of C`e'Inj F'(JUMATION
X ; a F. I hereby affirm that I am exempt Irom the Contractor's License MISC - R FE O ORD VALUATION F LL o 4 Law Port the following reason.(Sec 7031.5,Busimessa
nd Professions P RMIT IS ATI $/FT.
ISSUANCE Y 2 D 6.00
Hy Code:Any city orcounty which m(luires a permit to construct,alter,
¢ o ¢ 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
wo¢ requires the applicant for such permit to file a signed statement that TOTAL
wm he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
. z 0 Law(Chapter 9(commencing with Section 7000)of Division 3 o fthe ��QD� RJET
E o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 - 5 DRIES TYPE CONSTR.
n ; m by any applicant for a permit subjects the applicant to a civil penalty -
mfpot more Than five hundred Aollun[45001.]:
ALTER-DRAIN& VENT-WATER (EA,) 4.00 4r
❑ I,as owner of the property,or my employees with 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 of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself m of inch his own employees,for',Provided that such improve-
memtsarrIlucomldedonempldfeesale.Tided that sohe building GAS-EA.SV STEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 E IND ON PB Other
❑ I,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 docs not apply
to an owner of property
who builds or improves thereon-and who LAWN SPRINKLEIRS-OVER 5(EA.) 1,00 � �'"'
contracts for such projects with a contractors)licensed pursuant to ^7 aQ
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 an,exemp under Sec. B.&P.C.Port this
\ , reason WN WATER HEATER W/VENT 4.00
J( Date 40. -Owner LyL WATER SYSTEM 4.00 ACC.DATE Acc.FILE No.
"'OR S'CO\IPCNSATION DI-CLARATION X64" WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have o certificate of consent lu s,lFinssve-
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sre.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T29
z Z ❑ Certified copy is fled with Ile city impaction division.
FO Applicant MISC.- REFER TO ORD. Y [] NE Y ❑ NE]
ir T CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 c.
LLI > CO.NIPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
d O (This section need not be completed if rhe pennil in for one TOTAL Y N Y N�
Z hundred dollar,IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 'hall not employ airy person in any mann¢,so us to
U w become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. q.0p BUILDING fg
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex- _
r Z eruption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
OF Riop, of the Labor Code, you nmst forthwith nmtply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10/000C.F.M.) 3.00 FEE
CONS['RUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is lolled(Scc MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify that 1 have read this application and state(hal the above VENTILATION FAN (SINGLE) 3,00
information n estate. 1 agree to comply with all city unci county PLUMBING
hereby au and scute Taws relining to building construction,roon and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 4.00
hereby sonon rz roperty fives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
/ (We) .gree to slot, indemnify and keep hornless the City of MISC.- REFER TO ORD.
,- Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in Conatquenct of(be PERMIT ISSUANCE 3.00
granting ufthis permit. - - MECH.CONT. LIC.NO. MECH.
OTAL TOTAL ]
Signature of Appf ant/COmDTVor Ume
OFFICE COPY