0453 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN RNA Y
BUILDING PROJECT 1 DENTI FICATIONPERMIT NUMBER
B..LDING APPLICATION & PERMIT 0453
ADDRESS
N0.► BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME CITY. P . ELECTRIC PERMIT; ' .^FEE.,
NAME cr s UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
a 0 LIc.ND. LIGHTING FIXTURES 5.00/1.00
ADDRESS
r. RSS TOR'3 APPLIANCES-RESIDENTIAL 4.00
(�ff
�/ ✓5PHONE Q PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. COW 3.00
ARCH.OR ENG. SPECIAL CIRCU a 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER UP
I 15.00
APPLICANTS MOTORS BE Egf E SCH.
ADDRESS
SERVICE CHANGE 00K10.00
W m o III-
LICENSED CONTRACTORS DECLARATION
¢ v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
e,e, (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
o i
0 Professions Code, nd i
my license s in full for n �f ❑ ❑ ❑
z 'J! - Licen `Is Lic.. s Number
o u r O Date Contractor
ams P,BUIL'DING PERMIT,S"a'a?'
¢ ¢ i a OWNER-BUILDER DECLARATION ;'?7.,;;''�;INFORMATION:!irI ;i
S sa MISC.- REFER TO ORD
X N I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
_ I. o J Law far the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE
-sn Code:Any city ar county which mquimsa permit to construct,alter, 6.00 .J
a ¢< 0 improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
`x $ he is licensed pursuant to the provisions of the Contractors License
i i Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the Rr.'9Yv' . +Ar••r.•s
a
Businev and Professions Code)or that he is exempt therefrom and DTV. i < - PLUMBING PERMIT y y { FEE
¢=$ the basis for the alleged exemption.Any violation of Section 7031.5 (E�Ff,� 'ys, rc. '.X,:--„_ N f7r , _ 'r = STORIES PE CONSTR.
e. by any applicant for a permit subjects the applicantto a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).1:
❑ 1,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, Business and ProfessionsDRAINS-FLOOR,ROOF,AREACOND. 4.00
Code:The Contractors License Law don not apply to an owner of
property who builds or improve 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- GAS-EA.SVSTEM-1 4,00
meets are not intended or offered for sale.If,however.the building
or improvement is sold within one year of he did
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 ins- RES IND CON PB Other
prove for purpose of the.). INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property.he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.does Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts ract such projects Lwitha contncmdsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy there (� S c 3 ,Lab.y
Policy No o,L any�. z 2.
O ❑ Certified cop is hereby fumishe . FIRE SPRINK ENERGY T24
Z z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Applicant Y ❑ NE] v E] N[]Hy PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
Lu CERTIFICATE E EXEMPTION FROM WORKERS'
W > COMPENSATION INSURANCE PLG.CONTR. LIC.No. plc.
CL TOTAL Y N Y N
Z (This section Mrs need not be completed if the permit is for one . - ❑ ❑ ❑ ❑
hundred dollars(S 100)or less.) �. .. r a rn h ti v
U O mit is rtifyissuthatsin the p rformanceemploy of the arson rr forny whichrthisso as to QTY' ., -I MECHANICAL PERMIT] gsckr72 F�EE�'; d'-* slileEE_SUMMARY ay.. f j•
LL U become subject to the Workers'Compensation Laws of California. ••L.W..v .x 1 c�.l!ti. ._ H -' •H'Sv5
i Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING aSoJ
} us NOTICE 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
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1OA*C-F,M15.00 SEISMIC FEE 2 �
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(See. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,CN.CJ.
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and state that the ubuve VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 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 BTUI SEE FEE SCH. MECHANICAL
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 CONST.TAX
may in any way accrue against said City in consequence of the• PERMIT ISSUANCE 3.00
granting of this permit. MECH.CONT. LIC.NO. MECH. 's v..
TOTAL Ns" 41 L S,�I✓•'s:',.
( -5�- k'TOTAL.
Signature aj�ApphcanllComnctor Date s'.ij'
OFFICE COPY