7123 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER am LOIrvG APPLICATION & PERMIT
t• K. AOORESS BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
17-1 S�t„1�DvA Lcs.. In 7123
OWNER'S PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
• .W •GIG\11..1 -V, PHONE GJ3_54
CONTRACTOR
NAME UTLETS-SWITCHES-AECEP 5.00/1,00
"AME
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
'
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 PATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
` EIC.NO. SIGNS TRANS. 3.00
ADDRESS EN6. SPECIAL CIRCUIT rj.00 PERMIT VALIDATION
zlvEMP.METER OR POLE INS. 15.00 I,\ �
' nPPucarvrS MOTORS SEE FEE SCH. '
ADDRESS U MV(J-
SERVICE CHANGE 10.00 u
t o a LICENSED CONTRACTORS DECLARATION
s'Q o u 1 hereby affirm that I am licensed under provisions of Chapter ISSUANCE PATE
.y G vl (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PL EC
F w z I'm fessions Code,and my license is in full force and effect. ❑ ❑
6.0 m License ClassLic.Number
w Date Contractor
a y E BUILDING E IT
a re u OWNER-BUILDER DECLARATION `
E
;?LL r I hereby affirm that I am exempt Irom the Contractor's License MISC.- REFER TO ORD
INFORM TION'
uOa Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE VALUATION S/FT.
Code:Any city or county which requi,esapermit toconstruct,aher, 6.00
Qto¢ improve,demolish,(IT repair any structure,prior Or its issuance,also ELEC.CONTE. LIC.NO. ELEC.
to
O u,requires the applicant for such permit to Tile a signed statement that TOTAL PERMIT TO
o, w m w he is licensed pursuant to the provisions of the Contractors License
HZI Law(Chapter 9(commencingwith Section 70001ofDivision 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r o the basis'for the alleged exemption.Any violation of Section 7031.5 STO IES T CONSTR.
s3m by any applicant lora permit subjects the applicant to u civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
.trial mum than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP REB.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 F IXTUR ES-PER TRAP 4.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
•
himselforthrough lino or offered
however.
the
ibuildie GAS-EA.SYSTEM-I INC.40UTLETS 4.00 /
hment,imse are not intended or offered for sale.If,ed that such
the mpWing
or improvement is sold within one yea)of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builCcr will have the burden of proving that he did not build or im-
p•, lo,propos:of sale.). INDUSTRIAL WASTE INTER. 20.00 IND CON PB oma
L as owner of the property,ten exclusively contracting with ❑ ❑ ❑ ❑
Pic used contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS.- 1 INC 5 V.B. 5.00 s, ASSESSORS PARCEL NO.
turd rt owner
Code:The builds
o License Law does not apply
to an Owner of property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
I cls lisrOuch
ce...a swilh acontraclnrl sl licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
to Contruewr's License Law. '
I um exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 4.00
` „ Owner Date t WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
/X\ ') ITERSPENSA7TON DECLARATION WATER TREATING EQUIP. 4.00
I hereby alfinn that 1 have ace rtifical,c f consent to o,ifinsum' ,ZONING ENG.SITE NO.
I certii'Me of Workers'Compensation Insurance,or a certified
copy mercof(Sec-3800.Lab(:J.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ CcHifsod copy is hied tell, the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
ir D CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
Lu > COMPENSATION INSURANCE PLG.CONTE, LIC.NO. PLG.
0-Z (This section need not be completed if the permit is for one TOTAL Y❑ N[_ Y ElN❑
hundred dollars IS 100)orless.)
• U O I cattily That in the peTfornance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P- mil is issued,1 Shull not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
U a
Date-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING .
} In NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z amption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
prop Bions of the Labor Code, you must forthwith comply with . FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.NL) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000CEM.) 5.00 SEISMIC FEE
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. HEATING UNIT ITO 100,000 B.T.U.) 4.00 MICROFILM 1
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certily that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 /O
• information is correct. I agree to comply with all city and county PLUMBING
mxlinunces and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP•(Over 100,000 BTU)SEE FEE SCH. MECHANICAL /
above-mentioned properly for inspection purposes.
(We) agree to sure, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichPERMIT ISSUANCE 3.00 �- CONST.TAX
may in any way accrue against said City in consequence of the
n Of this MECH.CONT. LIC.NO. MECH.
)A -4 Al jkJL1 2. TOTA r TOTAL /
Si t col Appf mContractor Date
INSPECTOR COPY