4917 APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICAIPPON I PERMIT NUMBER'
BDILDINc APPLICATION & PERMIT A n� 7
ADpR 55 , _
' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 4 J I
WNER'a PLAN CHECK VALIOATI ON
r NAME Q ! OTV. ELECTRIC PERMIT FEE
I. / DNE ~
CONTRACTORS
UTLE1 G-St
ITCHES-RECEP 5.00/1.00
O�/i1' ucNo LIG
0 f�f3 - HT
INFIXTURES 5.00/1.00
roNTRacroR's
APPLIANCES-RESIDENTIAL 4.00
ADDRESS
�/ PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER .,
uc.No. - SIGNS TRANS. - 3.00
ARCH,OR ENG, PfjRMLIOATION
ADDRESS SPECIALCIRCUIT '5.00 YCA
zIP EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
ADOREss SERVICE CHANGE - 10.00
o o LICENSED CONTRACTORS DECLARATION1 hereby affirmthat 1 am licensed under provisioirsal'Chaprer 9 � g Is
h Q a (commencing wllh Section 7000)of Division 3 Df the Business unJ BLDG. ELECT. LG. MECH.
H o Professions Cole an m lirense is in full for fe 3 { - 0 ❑ ❑ ❑
Z o Licenu Class Lin.Numbe
o m Contractor
¢ m cr a OWNE -BUILDER DECLARATION _ BUILDING PERMIT
o a" MISC. REFER TO ORD INFORMATION
X ;u uHi I hereby affirm that 1 am exempt from the Contmnor's License VALUATION S/FT.
a, Law forthe following reason, 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Ew Cade:Any city occounty which requires a permit to construct,alter,
ELEC.CONTR. LIC.NO. 1 �f.x
¢ o improve,demolish,Or repair any structure,prior to its issuance,also ELEC. ( !�
A wO LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed Pursuant to the provisions of the Contractor's License
H
i 2 La.(Charter9(commencing with Section 7000)of Division 3 o fthe
¢ Business and Professions Code)or that he isexempt therefrom and CITY. PLUMBING PERMIT FEE
M H o the basis for the alleged exemption.Any violation of5ection 7031.5 TORIES TYPE CONSTR.
i;m by any applicant for u permit subjects theapplicant can civil penally ALTER-DRAIN&VENT-WATER (EA.14.00 /
of not more than five hundred dollars($5000.):
❑ 1,as owner of the property,or my employees with wages its BACK FLOW PROTECT. DEVICE 2.00 OCC.GRO RES. NITS
their sole compervation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractors 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 F o AR TOT L ACREAGE
[ himself or through his awn employees,Provided that such Improve'
mentsure not untended or offered for sale.If,however,the holding GAS-EA.SVSTEM-1 q,00
or GAS•EA.SYSTEM-OVER 4 IEA.) 1.00
improvement is sold within one year of completion, the owner. eulL Ne USE
builder will have the burden of proving that he did not build Or im-
Proveforpurposeofsale.). INDUSTRIAL'WASTE INTER. RES IND PB Omer
❑ 1,as owner of the property,am exclusively eommcling with 20.00 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS 5 PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property 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 Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
Cl I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Data Owner WATER SYSTEM 4.00 ACC.DATEACC.FILE NO.
WORK IiRS'COMPFNSATION DECLARATION IWATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a car Ificzl
copy thereof(Sec.3800,Lah.C.)�}/..
Policy No. Company„1/O/-'t t4/46
0 ❑ CerNfie Is hereby thiourea. FIRE SPR INK ENERGY T 24
Z A cent " y s/fleJ�{��wit the city inspection division, MISC.- REFER TO ORD. Y N Y N
P: m PERMIT ISSUANCE � 6.00
- � - CIIRTI ICATIiO' '%IiMPTlO ROM RKIiRS' FLOOD ZONE A.L.0 c.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
� Z
n
(This section needot he completed-il' the Permit Is for One TOTAL Y❑ N❑ Y 1:1N❑
hundred dollars($100)or less-)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California. '
Dam A licant BUILDING
a pp ALTER OR ADD TO MECH. 4.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex
F Z VK
emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE 5
1 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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.)7,50
Lender's Names - ELECTRIC
I certify that I lave read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
_ ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection proposes.
(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 ally way accrue against said City In consequence of the '
grantin II't ucr it MECH.'CONT, LIC.NO, MECH.
TOTAL, TOTAL
urc fApmIic.nIJC.nILhero - Date -
OFFICE COPY - "