5214 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING ., APPLICATION & PERMIT 5214
ADUREss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
Z L
OWNERS PLAN CHECK VALIDATION
f "AME QTY. ELECTRIC PERMIT FEE
//'. t
rAX1 f PRONE
CDNTRADTDRs UTLETS-SWITCHES-RECEP 5.00/1.00 -
I NAME
vv LIGHTING FIXTURES 5.00/1.00
CONTRACTORS l...l I�. APPLIANCES-RESIDENTIAL 4.00
AOOREss 1 t ,x `` II(_
S LINW Orv��a rG1S PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.On ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zm TEMP.METER OR POLE INS. 15.00'
APpucnrvrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
G u L~i 1 hereby affirm that 1 am licensed under provisions of Chapter 9 - ISSUANCE DATE
yaw (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H w z Professions Cod¢an�d{� se is in full to v r dyl�qL ❑ ❑
z 0 v. License Class(„_'�nLic.Number'L S 7`-v•S ❑ ❑
Q Y Dale C.7 �ContrnmoeS..�..�� e--S� e.
a OWNER-RUILDF-R DECLARATION BUILDING PERMIT,?�%i(.;_jy'+
REFER TO ORD INFORMATIONS
w ;LL H I hereby shirr that I ran exempt from the Conlrnctor'S License RISC.- VALUATION $/FT. -
FuO 04 Law for nffic ycit 11orcoun•ason.'See.7nesa IS,
permit weans Professions PERMIT ISSUANCE . 6.00 - PAM
Code:Any city or county whish requirese permit to consuanc ,also !!//''6N7 KK//
G 0 improve,Demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 u requires the applicant for such permit to file a signet)statement that TOTAL p IS TO
w m he is licensed pursuant to lire provisions of the Contractor's License AR- Q
4
Hzi
Law(Chapter 9(commercing with Section 7000)ofDoision 3 ofthc
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
8, the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; _, by any applicant for a permit subjects the applicant IDA civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 I{9 Of CBperh o
of not more than five hundred dollars(S500).):
❑ 1,as owner of the properly,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 (See 7044, Business and Profcsians DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
properly who builds or improves 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-
mmntsare not intended oroffered for sale.If,however,the budding 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(EA.) 1.00 BUILDING USE
builder will have tiro burden of proving that he did not build or no- RES IND CON pB Omer
prove far purpose of sale.). INDUSTRIALWASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Svc, 7044,Business LAWN SPRINKLERS- 11 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Codc: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 contracmds)licensed pursuant to
SEWER-SANITARY-STORM EA,200ft/5.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ l as exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
accolit
Owner Date WATER SYSTEM 4.00 ACC.OATE ACG FILE NO.
WORKHRS'COMPGNSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Copy thereof(Sec.3800,1-roC.). '
Policy No. Company
O' ❑ Certifiers copy is botchy furnished FIRE SPRINK ENERGY T24
Z z ❑ Certified copy is filed with the city inspection division. RISC.- REFER TO ORD. y � N� v ❑ N❑
F � Applicant
- PERMIT ISSUANCE 6.00 PtooO zoNE A.L.0 C. .
OC - CIiRT'I I'I(JOI OF EXEMPTION FROM WORKERS'
Lid1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. YE] N❑ Y ❑ N❑
d Q This section need not be completed if the permit is far Dols TOTAL
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work fur which this per- FEE=3UMMARV`*'�
LL F mit is issued,I shall not employ aI nano y manner so
hi as t0 QTY. MECHANICAL PERMIT FEE • .. ' `-
O L) hecolrµSu oyl�i 1t Worker' ens lio Lu o C,lifornia. 7 J�
DatcS-LL"�Ft pplicant 'ALTER OR ADD TO MECH. 4.00 BUILDING
a 7T
} N NO Chi TO APPhICANT: 11;attar ski thi Certificate sa Ex-
Z eruption,you should become subjec fo it' W ers'Compensation APPLIANCE 4.00 PLAN CHECK ,3 7
provisions of the Labor Code, you mus rthwith comply with FEE
U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10)MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby afirro that there is a construction lending agency for EXHAUST HOOD (WITHDUCT) 2.00
the performance of the work I'or which this permit is issued(Sec. MICROFILM
3097,Civ.C.).
HEATING UNIT(TO 100,000 B.T.U.) 4.00 '
,
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Addre,s
I eo7uty that l have read this application and State that the above VENTILATION FAN (SINGLE) 3.00
inlorination is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 gCONST.TAX
ordinances and state laws DelalingTo building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH,
above.mentioned property for inspection purposes,
(We) agree to Save, indemnify and keep heoNcss the City of MISC.- - REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which may in anywaccre against said City in consequence oPERMIT ISSUANCE 3,00me
rn t. MECH.CONT. LIC.INp �7oZ, /
plTe t/Contmetor Date
OFFICE COPY