14297 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN'ONLY
BUILD[NG PROJECT IDENTIFICATION .. PERMIT NUMBER -
nwLDINO APPLICATION & PERMIT
TADDRESS p
..,�v e' F`. I UILDING-ELECTRICAL-PLUMBING-MECHANICAL 1429.7
OW NE 'S - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
OIkWO.41, 'l^ PHONE 6�
CONTRACTOR'S
/ NAE OUTLETS-SWITCHES-RECEP' 10.00/1.00
Y- 4µ LIE,rvo.��� LIGHTING FIXTURES 10.00/1.00
• i�
CONTRACTORS - - APPLIANCES-RESIDENTIAL 4.00
ADDRESS •��
PHONE t•E�Q"�6 PANELS- 10.00 i DATE OF APPLICATION
ARCmT[CTPLAN CHECK FEE -
DR r PANELS (OVER 200 AMP) 20.00 - .
ENCIrvEE�� r r1 Ic,No. SIGNS TRANS. 3.00
ARCH.OR ENG. v f••� PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. -20.00 x
APPLICANTS '• -
ADDRESS MOTORS SEE FEE SCH. n 5%
SERVICE CHANGE 20.00 ~~
F oo LICENSED CONTRACTORS DECLARATION I/
U I hereby affirm that 1'am licensed under pron
ovisis of Chapter c) - ISSUANCE DATE
m< a. - (commencing with Section 7000)of Division 3 of the business and ,BLDG. ELECT. PLG. MECH.
H o z Professions C.de,and my license is in full to 'an cf •ctL _ ❑ ❑ ❑
I
o V - License Class - Lie.Number_
` O w . Uate 'L 9n.A r-r- Conl,actor �j `•
- a m �' ,T ^�4�- BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION INFORMATION
wo a Lh MISC.- REFER TO ORD
3 LL H I hereby affirm that I rep exempt from the Contractor s License VALUATION $/FT. .
H u o¢ Law for the following reason.(Sec.7031.5,business and Professions pERMfT ISSUANCE 10.00 '
Code:Any city or county which requires a permit to construct,utter,
2 a, ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.. ELEC. '
Lo 0¢ requires the applicant for such permit to file 0 signed statement that � TOTAL PERMIT 0
whe is licensed mmunint to the provisions of the Contractor's License
i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
M
a Business and Professions Code)or that he is exempLlherefrom and OTY. UMBING PERMIT a FEE
M 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 by any applicant8or a permit subjects tat applica_lit to a civil penalty ALTER-DRAIN -WATER IEA) 500 '
of not more than five hundred dollars($500).): . .
: -
❑ I,as owner of the property,Or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oce.GROUP REB.UNITS
their sole compensation,.will do the work,and lhe'structure is not
in ended or offered for sale (See. 7044, business and Professions - DRAINS-FLOOR,ROOF,AREA,COND. 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 FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own empoyees,provided that such improve-
mmre GAS-.EA.SYSTEM-1INC.4OUTLETS 6.00
es anot intended or offered for sale.If,Imw".,,the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 - BUILDING USE
builder will have the burden of proving that�he did not build or im-
provefor purposeofsale.). - INDUSTRIAL WASTE INTER. 30.00 .- RES IND CON PB 'Other
❑ I,as owner of the",.perry;run exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044„Busineis 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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
' contracts for such projects with a emromcto(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. - , TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00 -
reason
Owner - Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPIiNSATION DECLARATION. WATER TREATING'EQUIP. 5.00 '
I hereby affirm that I'have a certificate of consent to self-insure. ZONING
\/ or a certificate of Workers'Compensation Insurance,or a cortified ENG.SITE N0.
�l copy thereof(See.3800,Lah.C.)
Policy No. Company
0 ❑ Certified 'opy is'hereby furuishud, r FIRE SPRINK ENERGY T24'
Z Z ❑ Cerci_ py is 1 ed �v7t,h t�heity, inspection division.
-A if �'bt9, C I. MISC.- REFER TO ORD. YE] N❑ YQ ,,'N❑
n, PERMIT ISSUANCE ' 10.00
CC - 'URTIFI CAT[:OIs ISXIiM PTION I°ROM WORKERS' s- FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
(LO This section neednot be completed if the permit is for.rte TOTAL v Y❑ N❑ Y [:DN❑
0 Z, hundred dollars(S 100)or less.) ' '
U O 1 certity that in the performance of the work for which this per- CITY MECHANICAL P T FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
0w bee.ruesubject to the Workers Companso ion Lawsof California. BUILDING
y - Date Applicant - ALTER OR ADD TO MECH. 5.00
} N NOTICE'I'O AI'I'LICAN'f'. 11;after making This Cert ilieute of I's-
-,F...Z emption,you should become subject to the Workers'Compensation APPLIANCE \ 5.00 PLAN CHECK '
.U
provisions of
the Labor Code, you must forthwith comply with FEE
suchl isthis permit shall he deemed revoked. AIR HANDLING UNIT TO 1!0=, CF. .00
CONSTRUCTION LENDING AGENCY AIRHANDLINOUNITIO 1 .16'.00 SEISMIC.FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WI UCT) 5.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
1 certify that I have read this application and scute that the above VENTILATION FAN (SINGLE) '4.00
information is correct.I agree to comply with all city and county PLUMBING '
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Ow,1130,000 BTU[SEE FEE SCM. MECHANICAL -
above-mentioned property for inspection purposes.
(We) agreeto save; indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertinoan•against liabilities,judgments, costs and expenses which CONST.TAX
may in y way accrueragainsA sai City in consequence of the .PERMIT ISSUANCE 10.00 /ES
' gNalin -this L1 MECHaCONT. LIC.NO. MECH.
TOTAL 'ISL, TOTAL _
-� Sign tore of p , ant/Contractor Data Or '
OFFICE COPY _ _ _