5695 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER B°"°'"° APPLICATION & PERMIT
5695
ADDNESa
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
ER'a I PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE lcql -A
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
1.
DUC.No. LIGHTING FIXTURES 5.00/1.00
cions
ADDRESSB - - APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
onnCHl ECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Llc.rvo. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
zap TEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS 1 `
Aven /� SERVICE CHANGE 10.00
uOF+o o LICENSED CONTRACTORS DECLARATION �r LL
<v u I hereby affirm that I am licensed under provisions of Chapter 9 00` /r4 ISSUANCE DATE
v,�'R (commencing with Section 7000)of Division 3 of the Business and
y¢ N BLDG. ELECT. PLG. MECH.
r D z 1'mmssions Cn F,a licnnse is in full for c 7 - ❑ ❑ ❑ ❑
z o T - Licen'•C s�ss Lon Numher
m r Uareil__.- Comractor -
a BUILDING PERMIT
¢ o M st u OWNER-BUILDER DECLARATION INFORMATION
E:
; N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
U u o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE P/{VPLtM1TI0N SIFT.
Code:Anycityorcounty which requires a permitto construct,alter, 6.00 L'YLL ,�l^
IS U Q p improve,demolish,Or repair any strue(ure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
u w m IS requires the applicant for such permit to file a signed statement that TOTAL
he is licensed pursuant to the provisions of the Contractor's License 1.HNIT TO
F 2 r
Law(Chapter 9(commencing with Section 7000)of Division S of the
4 o Business and Professions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of SeCtion7031.5 O q�loisjlflo TYPE CONSTR.
Cis by By applicant for a permit Subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five Imndmd dollars($500),):
❑ I,as owner of the property,or my employees with wages asggCK FLOW PROTECT. DEVICE 2.00 OCe.GROUP RES.UNIT
their sale conhpensation,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 tot apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
provefor purpose ofsale.). INDUSTRIAL WASTE INTERRES IND CON PB OtIm,
❑ I,as owner of the property,am exclusively contractiSit g. with 20'00 ❑ ❑ ❑ ❑ ❑
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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts far such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl I am exempt under Sec..,IL&P.C.]or this WATER HEATER W/VENT 4.00
reason
Ow,0 Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 herehy affirm that I have a certificate(it consent to sell'-insure,
ors certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
ropy Ihereof(Sec.3800,Lab.C.L - -
PolicyNo.�p�17-/ m
Copany�TItT4 )KLI
Q ❑ Certified copy is hereby furnished. I FIRE SPRINK ENERGY T.24
Z 2 [Y¢e RifigJs Dopy is filed with the city inspection division. - -
O Applicant llll - - MISC.- REFER TO ORD. Y ❑ IN 11 Y ❑ NO
CC CERTIFICATE OP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG,
CL CI IThis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [:] NC]N
hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- GTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F. mit is issued. I shall not employ any person in any manner so as to
OW become subject to the Workers'Compensation Laws mf California.
y Cum ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} N NO'TICI:TO APPLICANT'. IL after making this Certificate of lix-
♦- 2 enlption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you nlmst 10ninvith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.RM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction leading agency for EXHAUST HOOD(WITH DUCT) 2,00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CY.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders NamAddress Lender's ss
HEATI NG UN IT(OV ER 100,000 B.T.U.P.50 ELECTRIC
I certify that I have read this application and state(hat the above VENTILATION FAN (SINGLE) 3.00
ur.mrmrwo is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-O"13 H.Ror 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCN, MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against olid City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
7--N��7r- TOTAL TOTAL �.
Shgmgtureof AppbcantjConlraclor Date
OFFICE COPY
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