5834 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
AOORESS
� BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
M r fZ)Jq4/4 III ELECTRIC PERMIT FEE
P NE
CONTR T
Na E 1OUTLETS,SWITCHES-RECEP 5.00/1.00
I . 'LIGHTING FIXTURES 5.00I7.00 ,
CONRAC
ADORESAPPLIANCES-RESIDENTIAL 4.00
R N PANELS 5.00 DATE OF APPLICATION
OR
RCNI EC SIGNS 5.00 PLAN CHECK FEE P.C.NO.
'
ENGINEER
sec.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION
a 0 u I hereby affirm that I am licensed under provisionsof Chapter 9 ISSUANC DATE
N a H (commencing with Section 70001 of Division 3 of,lhe Business• BLDG. ELECT. PLG. MECH.
Hoz Professions Code,anti my license is in full force f El
O= — License Class Lic.Number
L.o Dates Contractor El E
a m f
o a 0 (w' bl -B
x)ILDIiN UECLANATI BUILDING PERMIT
w 3:u y I hereby allirm that I am eempt from IIIc Contractor's License MISC.'— REFER TO ORD INFORMATION
r .. N j
law 1'or the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6 00 VALUATION
wr Code:Anycity orcounty which requires a permit to construct,alter,
rtQ Q Q improve.demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
e_ w m, requires the applicant for such permit to rite a signed statement that TOTAL PERMIT TO
hpursuant
e is licensed to the provisions of the Contractor's License
r z i law(Chapter 9(commencing with Section 7000)of Division 3 fthe
ao Business and Prut'essions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X r
F m the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a3 — by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500):):
❑ 1,as owner of theproperty,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will d^the work,and the structure is not
intended or offered for sale (Sea 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 TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mGAS-EA.SYSTEM-1INC.4OUTLETS 4.00
rumpus are not intended or offer.]for sale.If,however,the building
or improvement is sold within one 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 on-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER200g RES IND CON PS Dow,
.
❑ I,as owner cul 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 CmIC:'The Contractor's License Law does not apply r
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracbms)licensed pursuant to '
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ion exempt under Scc. ,B.&PLC.for this WATER HEATER W/VENT 4.00
anon
Owner Date WATER SYSTEM 400 ACC.DATE ACC,FILE NO,
WORK Ii RS'COMPENSA'I[ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm tial l have u certificate ofamsent msel6bi,mv, ZONING ENG SITE NO.
or a certificate of Wor ompc 'tion Insum c or a certified
n C.1. O
O h� y
e I is'hereby fur e
C Y, ( FIRE BPRINK ENERGY T-24
Z Z ❑ Certified p d h t e ity i^p 'on t ry MISC.- REFER TO ORD.
D Applicant V N� Y N� '
H H s PERMIT ISSUANCE
CENTIPI '1'I>OF IiX1iMPfION FROM WORKERS' S•� FLOOD ZONE A.L.U.C.
W JOMPIiNSA1'ION INSURANCIi PLG.CONTR. LIC.No. PLG.
Z of
(Phis seclidn need not be completed if the permit is for one TOTAL Y❑ NC] Y� N�
U O hundred dollars 1$100)or less.)
I certify that in the performance of the work for which this per, OT,Y. MECHANICAL PERMIT FEE,, FEE,SUNIMARIT,�'A`'y.
LL U mit is issued,I shall not employ any person in any manner m as to
become subject to the Workers'Compensal ion Laws of California.
y
Dane—Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NO'I'IC17 TO APPLICANT:,If,after making this Certificate,of Ex-
I— Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provislans of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 110MC.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 issued(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I,certify that I have read thisupplicalion and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and County PLUMBING r
ordinances and state laws relating to buiiding'constRmtion, and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
ahovrmmntioned properly for inspection purposes. BOILER-COMP hover 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in any way accrue against said City i c sequence of th PERMIT ISSUANCE 3.00
gr ting of this pe I - MECH.CONT. LIC.NO. - MECH. s
TOTAL TOTAL
S' n h c f 'ontrector le
OFFICE COPY
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