8235 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — ALL POINT PEN NLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFIC APPLICATION & P T
eulw c
SVD 0s kA' A BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 82
OWNERS'
n ^ l ^�7 PLAN CHECK VALIDATION
' BIS-FV PN E 'j t OTV. ELECTRIC PERMIT FEE
CONTRACTORS' 1 �v -n_ -706 y�j LIGHTING
-SWITCHES-RECEP 10.00/1.00
j�� LI o, 41}�1U( LIGHTING FIXTURES 10.00/1.00
NTRACoR's ye
' .,s PPLIANCES-RESIDENTIAL 4.00
A0 �
PANELS 10.00 GATE OF APPLICATION
ARCHITECTP,ANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3,00 pAIITA
` ARCH.OR ENG. SPECIAL CIRCUIT S,QQ p PERMIT VALIDATION
ADDRZIP EMP.METER OR POLE INS. 20.00 'APR F 319!15
APDL ANT MOTORS SEE FEE SCH. a,�
s \J SF eA SI3 I SERVICE CHANGE 20.00 ,Gley of Cupertino
w
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a w
u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
YA Q H BLDG. ELECT. PLG. MEC
r z Professions Code,and i nse is in full fore ff t.
Oi v`_{C License Cla Lic.Number ❑ ❑
m H DateContractor
<y s
Ic lL
Ma OWNER-BUILDER DECLARATION BUILDING IFERMIT
oa' u INFORMATION
w; m I hereby infirm That 1 am exempt from the Contractor's License MISC.— REFER TO ORD
o J Law forthe followingnason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
,A0 Code:Any city or county which requires a permit to construct,alter,
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w0 M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
2 m he is licensed pursuant to the provisions of the Contractor's License
z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the
i 4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X I$ the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES I I TVP CONSTR.
by anyapplicant for a permit subjects the applicant macivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5,00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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 Professions DRAINS- OO OOF REA N 5.00 d
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 O SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
mentsarenottntendedoraf(ereoyees,prove. ided
that such
cbuilding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM'-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or Im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CDN PB Other
.
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 8.00 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 SPRIN ERS-O ER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER ANITAR OR A.200ft
the Contractor's License Law. / TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—,B.&P.C.for this I WATER HEATER W17M 00
reason
Owner Date WATER SYSTEM 5.00 O
ACC.DATE ACC.FILE NO.
WORKERS'COMPE:NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby al I, that I have a car ificute of consent to self-insure, ZONING ENG.SITE NO.
or a certifcete of Workers'Comp Isation Ins ante,ora 'ertified
im re ab.C.
Po I �pany
❑ Certified copy is hereby nished. FIRE SPRINK ENERGY T24
Z Z ❑ ertified P Is I el with Ie city inspection division.
O icant _ n/I n MISC.- REFER TO ORD. .Y❑ N❑ V ❑ N❑
to CE RTI FICATE OF F;XEMITION PROMPROM WO PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG. 0 R. LIC N . PLG.
fL 0 (This section need not be completed if the permit is for ane / " q TOTAL I&FV❑ N❑ V[:] N[]
LD Z hundred dollars IS 100)or less)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emplion,you should become subject to the Workers'Compensattoo APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith Comply with FE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNI ) 4.00
CONSTRUCTION LENDING AGENCY IR HANDLING UNIT(OVER 10 C.F.M.) .SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCTI 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 H EATI N G UN IT ER 100,000 B.T.U.) TRIC
Lender's Address
I re,Dil'y that I have read this appltcttion and state That D®above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county PLUMBING /0
ordinances and state laws relating to comply
itbuilding construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby aotimrim representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH, w MECH
above-mentioned property for inspection purposes, r►'�
(We) agree t save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again t liabilities,judgments, costs and penses which +^ T.TAX
?Way in any wa accrue against said City in cons uence of the PERMIT ISSUANCE
mnti g f si J �� MECH.CONT. LIC.NO. MECH.
lKJ O� To TOTAL I 6
Signature o Applicant/Contractor D to
F
OFFICE COPY
I