11453 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
9UrDING APPLICATION & PERMIT /....
ADDRESS -`
V �' (AJ, BUILDING-ELECTRICAL-PLUMBING-MECHANe�{L � 11453
OWNERS PLAN CHECK VALIDATION
"AME
ELECTRIC PERMIT FEE
- / I / PHONE ;ZMOOY-
CONTRACTORS
NAMEI / O�� UTLETS-SWITCHES-RECEP 10.00/1.00
L& Ctn /AO Y71GK UC.NO. �ZUSG7 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
W (X fCS//Or/� PRONE / VY/V
j PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc,NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 Q
o O LICENSED CONTRACTORS DECLARATION PAMW (a �b
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a (commencing with Section 7000)of Division 3 of the Business and -,, BLDG. ELECT. PLG. MECH.
F w i Professions Code my license 1s In
full'0rs'�,a " ❑ ❑ ❑
z o m - License Clasg Lic.Number T
Q m ta Uale � Contractor JJQ' 1
m¢¢ •1 O HER-BUILDER DECLARATION v ^ Cuoe��n� BUILDING PERMIT
Z o d uINFORMATION
w g: u w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
HuOJ Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 10.00 rT,- VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alley
a ¢< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O M requires the applicant for such permit to file a signed statement that TOTAL 3IJ
A w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F z i Law(Chapter 9(eommencing wi th Sect ion 7000)olDivision 3 of the (i77
< Business and Professions Code)or that hm
e isexept therefrom and QTY. PLUMBING PERMIT FEE
W I- the basis for the alleged exemption.Any violation of Section 7031.5
malty STORIES TYPE CONSTR.
a by any applicant fora permit subjects S5000.he licanuoacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred Dollars(5500).):
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,GOND. 5.00
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 5.00 So.FT,FLOOR AREA TOTAL ACREAGE
hijusclf or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsalelf,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
O I,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ 11
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
O I am exempt under Sec. ,BARC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACGDATE ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent toself-insure,
or a certificate of Workers'Compensation Insurance,or a cerci Oed ZONING ENG.SITE NO.
copy thereof(Sec.3800,1ab.C.I
Policy No, Company_SL
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY Ti4
Z Z 4Certified copy s led with it, yiy ection division.
F- O Applicant_ yuR. - MISC.- REFER TO ORD. ❑ � ❑
Y N V N
T CIiRTI FICATfS P EXENPTIO. PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL Y❑ N V ❑ N
Z hundred dollars IS 100)or less,)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mil is issued, I shall not employ any person in any manner So as to
O L) become subject to the Workers'Conlpensulicn Laws of California.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICI7 TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code, 5.00 PLAN CHECK
p you must forthwith comply with C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(T0 10,000QF.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT TO 100,000 B.T.U.) 8.00
Leader's Name HEATING UNIT(OVER 100,000 B.T.U.19.50
Lender's Address ELECTRIC U"
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILERLUMBING
ordinances and state laws relating to building construction, and (3 H.P.H.Por 100,000 B.T.U.) 6.00
hereby ambr ive representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgm , costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may m any way accrue against id ity consequence of the
granting Of thisa it, (N MECH.CONT. LIG NO. MECH.
7 PG TorAL TOTAL
Signal pplicanl/Conlmc r to
OFFICE COPY