3016 (2) APPLICANT TO FILL IN INFORMATIQNYVI-THIN RED,LINES -,USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
h RLILONG APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICA -PLUMING-MECHANICAL0-Y lQ 6
OWNER'S =' PLAN CHECK VALIDATION
NAME D Ao CITY.t .ELECTRIC PERMIT'.` I *FEEL
Q./!/�D goradf k Jk
PHONE
CONTRACTOR .. .
NAME OUTLETS-SWITCHES-RECEP 5.00/100
LIC.NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTOR 5 - " - -APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT
on SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
.sec.No. SIGNS TRANS.ARCH.OR
3.00
ADDRESS ENG - SPECIAL'CIRCUIT '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S AF11
AODREss MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 woo LICENSED CONTRACTORS DECLARATION -
U I0 1 hereby affirm that I am licensed under provisions of Chapter 9 -
Q Z w - ISSUANCE DATE
h < (commencing with Section 7000)of Division 3 of the Business and
r D i. Professions Code,and my license is in full force and effect.' BL❑DG. ELECT. PLO. MECH.
o 0=W License Class Lic.Number
Date Contractor
at
Lt-
0
UILOI G'PERMIT+ty'
Ic rt w a OWNER-BUILDER DECLARATION py,. "
o,iU INFORMATION'r,,,x,;
X ;LL r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u ¢ Law far the following reason.(Sec.7031.5,Businessand Professions UATION $/FT.
PERMIT ISSUANCE 6.00,A Code:Any city or county which requires a permit toconstrucl,alter, 'm wM FO imprve,demolish,or repair any structure,prior to its issuance,also ELIC.CONTR. LIC.N0. ELEO
- m u requires the applicant,for such permit to file a signed statement that TOTAL
6 w he is licensed pursuant to the provisions Of the Contractor's License PERMIT TO ,
riQLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe WOO F7 J`/�0✓!�
E 4 0 Business andProfessionsCode)or that he is exempt therefrom and QTY. PLUMBING PERMIT Cot§
IvI- $ the basis for the alleged exemption.Any violation of Section 7031.5 O C.I' s TYPE CONSTR.
H3 - by any applicant for a Permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 2.00 -CIT-Y-01
theft sole compensation;will do .,the work,and the is not p RES.UNITS_
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code.The Contractor's.License Law does not apply to an owner of
properly who builds of.improves thereon,and who does such work FIXTURES-PER TRAP 4.06 SOFT.FLOOR AREA TOTAL ACREAGE
himself ments re through his own employees,provided ever,t h impro not
within
or rone year
If,however,the owner, - GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1,00
proveof will have the burden. proving that he did not build or int- BUILDING USE
prove for purpose of sale.). - I NDUSTR IAL WASTE INTER. 20.00 RES IND CON PB Other
❑ d as owner of the property,ae'proj'project
(Sy contracting with ❑ ❑ ❑ ❑ �,
and Pro contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply to antr owner of property who builds tr improvesthereon,uand who LAWN SPRINKLERS-OVER 5(EA,) 1.00 '
contracts for such projects with a contraclorf s)licensed pursuant to '
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8,00 TRACT No. PARCEL No.
❑ I am exempt under Sec. ] - ,B.&PC.for this WATER HEATER W/VENT 4.00
1 reason'
/f Ownc Dxjc- � WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMP SATION DECLARATION WATER TREATING EQUIP. 4.00
hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified -ZONING .ENG.SITE NO.
copy thereof(Sea.3800,Lab.C.).
Policy No: . Company
0 . ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
P:IO Applicant - MISC.'- REFER TO ORD. Y[J N❑ Y 0 r C]
= rn - PERMIT ISSUANCE
- - CERTIFICATE EXEMPTION FROM WORKERS' C 6.00 FLOOD ZONE A.L.u.C.
LUION INSUILG
W > (This section e0Eed nolt ba come a ed Rif lhe�petmiL is for one PLG.CONTR. 'LIC.NO. TOTAL V '.N� V N❑'
ao
Z hundred dollars(8100)or less.)
U O 'I certify that in the performance,of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE.SUMMARY+' ,
LL U mil is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
w Date - Applicant BUILDING / O J
} y NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
♦- emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK �•r
provisions of the'Labor Code, you must forthwith comply with FEESI� 33
U such provisions or this permit shall be deemed revoked.. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is aeonstruction 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 H EAT[NG UN IT ER100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have readthis application and state that the above VENTILATION FAN (SINGLE) 3.00
v. 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.) 4.00
hercby',authorize representatives of.this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD,
Cupertino against liabilities,judgments;costs and-oxpenses which CONST,TAX
may any way accrue gainst 'd City in consequence of the PERMIT'ISSUANCE 3.00
IRS I g' this per] MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 3I _-
igna[ureofApplicantlConlruc to ,.
OFF ICECOPY '