4300 APPLICANT JG FILIL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITINUMBER
X a ILNGq�� APPLICATION & PERMIT
A001 as
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL '�
OWNER'
NAME _ PLAN CHECK VALIDATION
r 3'� QTY. ELECTRIC PERMIT FEE
CONTRACTOR
O AC G PHONE �'S�_
0 NAMERAcroas UTLETS-SWITCHES-RECEP 5.00/1.00
sec.No. . LIGHTING FIXTURES 5.00(1.00
CONTRACTOR s
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
non.OR ENG SPECIALCIRCUIT 5.00 PERMIT VALI DATION
ESS
ZIP ITEMP.METER OR POLE INS. 15.00
aGDAES
S s MOTORS SEE FEE SCH. ,kiR
SERVICE CHANGE 10.00 _ I " "
V1
LICENSED o o LICIiNS1iU CONTRACTORS DECLARATION Q o-� �
< u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yam (commencing with Section 7000)of Division 3 of the Business and B1 (SECT. PLG. MECH.
r D z Professions Code,and my license is in full force and effect / a ❑ ❑ ❑
z o 91- License Class Lie Number -
9 m r w Dale Contractor
a m f
a ¢ OWNER-BUILIJER DECLARATIONBUILDING PERMIT
o a u INFORMATION
w ; N I hereby affirm that I am exempt from the Contractor's License, MISC.- REFER TO ORD
L O a Law for the followin reason:(Sec.7031.5,Businessand Professions / VALUATION .$/FT.,
g PERMIT ISSUANCE 6.00 1/O_
eo Code:Any city or county whiny requirese Hermit toconsuanL,also 00
<0 improve,demolish,or repair any structure;prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
e. wC u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$w he is licensed,pursuant m the provisions of the Contractor's License _ D�
FZ> Low(Chapter 9(commencing with Section 70001of Division 3 ofthe /C 0Oez Race
a Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ 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 do the work,and the structure is not
intended or offered for sale (Sec. 7044, Busine s and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not ap ly to an owner of
property who builds or improves thereon,and ho does such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR AREA Total ACREAGE
himself or through his own employees,provided that such improve- -
mentsarenotintendedor offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.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- RES IND DON Pa Omer
prove for purpose of sale.). . INDUSTRIAL WASTE INTER. 20.00
❑ L as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the projectBusiness LAWN SPRINKLERS-1 INC5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Con tractor La does s License Law docs not apply
to anowner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contruclor(5)IicenuJ purstmnt to
the Contractor's license law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00
reason
DateOwner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT'ION DECI ARAT4A WATER TREATING EQUIP- 4.00
1 herehy affirm that 1 have a certificate ofconsenlto self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.), ,
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SHRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. C- REFER TO ORD. -
O Applicant MIS .Y❑ N❑ Y ❑ N❑
CC W C17RTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.D. ,
L COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. I.G.P -
' d O (This section need not be completed if tire permit is for one TOTAL Y❑ N❑ Y ❑ No
D Z hundred dollars(S 100)or loss.) -
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F' mit is issued,1 shall not employ any person in any manner so as to
U become subject to Ilse Workers'Compensation Laws of California. /
O w Date Applicant BUILDING
It. ALTER OR ADD TO'MECH. 4.00
F- to NOTICE TO APPLICANT: If,after making this Certificate sa Ex-
~ ? empision you should become
e, you must
Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 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. MICROFILM '
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.P.50
Lender's Address EL CTR IC
I certify that l hr,c o,l l this applicut ion and state that the above VENTILATION FAN (SINGLE) 3.00
�oidina nes n correct. I agree to g to b with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or.100,000 H.T.U) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)'SEE FEE SCH. MECHANICAL
above mentioned property to,inspection purposes.
(We) agree Io save, indemnify and k mics, the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgment costs d expenses which CONST.TAX
(� may in any wa ccrue a st City i consequence of lite PERMIT ISSUANCE - 3.00
Sol
n his rmit, f MECH,CONT. LIC.NO. MOTAL
tar of Applica [jContmctnr �)a[c - TOTAL �7�D
OFFICE GOP