4738 >APPL:ICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALI. POINT PEN ONLY f
',F• BUILDING PROJECT IDENTIFICATION : PERMrt,NUMRER
aDtD APPLICATION & PERMIT 7 ?O.
'meEDI s I J 0
RG BUILDING -ELECTRICAL-PLUMBING-MECHANI
D 2.4o �I�N
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'OWNER'S r. T a, 't�✓ "t AN CHECK VALIDATION
{ NAME OTY. ELECTRIC PERMIT FEE'
- I@- Ow _ h /0
,
NAME crony OUTLETS-SWITCHES:RECEP 5.00/1.00
NAME
Iruc.NO: 1gg1 L LIGHTING FIXTURES 5.00/1.00
CONTRACTORS - - 'APPLIANCES RES 4.00
IDENTIAL -
ADDRESS
PANELS 5.00 GATE OF APPLICAT ION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C,NO.
OR
ENGINEER !
UNC" Lm.NO. SIGNS TRANS. 3.00
AENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDR.ORESS
:zu=1 EMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH,
ADDRESS
- SERVICE CHANGE 10.00
. 02 - LICENSED CONTRACTORS DECLARATION NP
/ra/
a I hereby affirm that 1 am licensed under provisions cf Chapter 9 3 Nr0 - S� ISSUANCE DAT
H Q w (commencing with Section 7000)of Division 3 of the Business and BLDG. EC PLG. MECH.
H c z rofessions Cod n_d license is in full fere•a td effe t l p (;&A�
❑ ❑ ❑
z o - License Class '� Lic.Numher�Jyv�y' - t
o r Date 7--1 Contractor . VS I
¢ y f d - I O ,$;v` '.BUIL INGTERMIT,','"_"•
rc ¢ OWNER-BUILDER DECLARATION INF,ORMATION�",*
o-0 MISC.- REFER TO ORD " 'P� ``
'w u I hereby affirm that 1 am-exempt from'the Contractor's License -VALUATION $/FT.
F l� oa Law for the following reason.(Sec.7031,5,Businessund Professions PERMIT ISSUANCE 6.00 O` ,
Code:Any city or county which requires a permit to construct;alter,
K2 ¢ improve,demolish,or repair any,structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C LL, requires the applicant for sack permit m file a signed statement that N ad. / �L TOTAL � PERMIT TO
e w m he is licensed pursuant to the provisions OI'the Contractors License -
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofrhe ,'pWMBING PERMIT s +PEE' G
Business and Professions Code)oethat he is exempt therefrom and CITY:y"
K f`o the basis for the alleged exemption.Any violation Of Section 7031.5 r d '"r -� _ STORIES TYPE CONSTR.
a '3m by any applicant fora permit subjects the applicant toa civil penalty ALTER-DRAIN III VENT-WATER (EA.) 4.00 -
turner more than five hundred dollars($500).1:
❑ 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 clothe 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.or through his own employees,provided that such improve-
entsarenotintendedor Offered far 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 (EA.) . 1.00 RUILoIN USE
builder,will have the burden of proving that he did not:build or ml- -
prove for purpose oCsale.). I NDUSTR IAL'WASTE INTER. 20.00 -RES IND PR Omer
'❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ' ❑
licensedcontractor's to construct the project(Sea 7044,Business LAWN SPRINKLERS-.1 INC 5 V.B. 5.00 ASSESSO PARCEL NO.
and Professions Code:The Comraclor.'s License Law does not apply -
R,as owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for'such projects with a contraclne O licensed pursuant to -
theContractor'sLicensed-aw. ' SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ I um exempt under Sec ,BAP, . for this WATER HEATER W/VENT 4.00
reason
Date -- - "owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS:COM PENSATION DECLARATION WATER TREATING EQUIP.. 4.00 .
.I hereby affirm that I have'acertificate ofconsent to self-insure, ZONING
ore certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy th,R of(See'3800,Lab.C.).
Policy No. Company' i
O Certified copy is hereby furnished. - FIRE SPRINK ENERGY T 24
z gCcrtifird 'opY is filed ih the-cltY inspection division.
Applicant L -•t� MISC.- ' REFER TO ORD. Y ❑ N❑ Y ❑ N❑
- PERMIT ISSUANCE " 6.00 - .L.u.c.
�'- CERTIFICATE OI°EXEMPTION FROM WORKERS' FLOOD ZONE A
LU'� COMPENSATION INSURANCE. PLG.CONTE. - LIC.NO. PLG.
0_'C1 This.section need not be completed if the peris for one TOTAL V❑ N❑ Y ❑ N❑
D Z hundred dollars($100)orless.) P - ' • -
N x 3 y "
U O I certify lhct In the performance of the work for which[his per QTY' + MECHANICAL'PERMIT'`',x:r x `.FEE+ ti "•FEE`SUMMARY
LL I-' ' mit is issued,I shall not employ any person in any manner so as to A' _ , = g , p ." - t+
U become subject to the Workers'Compensation Laws of California. P
O a Date ' Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
- N NOTICE 1PP
'O ALICANT: If,after making this Certificate of F, - •,
FZ eruption,you should become 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 10,0MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DMC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that thereis a construction lendimy 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 ` p
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 .ELECTRIC
( certify thatl have read this application and stat,that tire above VENTILATION FAN (SINGLE) 3.00
• information is correct I agree to comply with all city and county' PLUMBING
ordinances and orate laws relating c to comply
with construction,cityand co and - BOILER-COMP(3 H.P.or 100,000 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH: MECHANICAL
v above-mentioned property for inspection purposes. .;
(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 said City in wamyuence offhe
granting of this permit MECH.CONT.'t LIC:NO. MECH. A,
TOTAL
L'
Signature OFApplican[/Contractor Uutl TOT- '
OFFICECOPY