3298 (2) -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/ BUILDING PROJECT IDENTIFICATION PEReNOWY
BUILDING APPLICATION & PERMIT 8
IPOUT v
OU Tb t4 r D� N I11 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NAME 1.J 1 7����� - PLAN CHECK VALIDATION
• DTV. ELECTRIC PERMIT FEE
L7 SSS _ PHONE2S�-D/OO
CONTRACTORS 01 LA 4J L54UTLETS-SWITCHES-RECEP 5.00/1.00
91.3 'L ,
ADDRESS
V LIC,No. LIGHTING FIXTURES 5.00/1.00
DoRs - - APPLIANCES-RESIDENTIAL 4.00
DREss
PRONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.D0 PLAN CHECK FEE P,C.NO.
OP
ENGINEER
UC.NO. SIGNS TRANS. - 3.00
ADD ESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ASrs
ADDU MOTORS SEE FEE SCH.
ADDRESS
s
W r z - _ SERVICE CHANGE 10.00
Foo
LICENSED CONTRACTORS DECLARATION /
u vI hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w<w (commencing with Section 7000)of Division 3 of the Business and BLDG. PLG. MECH.
F,y i Professions Code,and my license is in full force and effect. ❑ El 11z N o m- License Class Lie.Num her
Z2 z f o Date Contractor
IVIAt*j
¢ ¢ w < OWNER-BUILDER DECLARATION UI N MIT
MISC.- REFER TO ORD INFORMATION
w ;LL N I hereby affirm that I am exempt from the Contractor's License ��({1I 7� N .{ $/FT.
F u o¢ Lew far the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 CLLhyyrLBpel lin
Coder Any city orcounty whichrequimsapermiltoconstnmgalter, �' �-v
N rlor to its issuance,also ELEC.CONTR. LIC.NO.
M ¢ o improve,demolish.or repair any slruclure,=p ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
es u he,is licensed pursuant to the provisions of the Con(rstor's License
Fza
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
2 N G the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
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)J,
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do ora work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code.The Contractor's License Law does not apply to an owner of
property who builds orAmprovas 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-
mems are But intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1INC.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 the burden of proving that he did not build or im
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON Pa Orner
❑ I,as owner of the property, In exclusively contracting with ❑ ❑ ❑ ❑ ' ❑
licensed 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 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 contractors)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.&PCfothis WATER HEATER W/VENT 4.00
reason
he z. Ow y t WATER SYSTEM 4.00 ACC.DATE ACC.FILENO.,
DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, -
or a certificate of Workers'Compensation Insurance,of a centA ZONING ENG.SITE NO.
copy Ili ereo f(See.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby fumishod. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant - Y ❑ N❑ Y ❑ N[]I' rn
Lu CIiftTIFlCATE OF EXEMPTION FROM WORKERSPERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.'
W > COMPITSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
1 O (This section need not,be completed if the permit is I'or one TOTAL. Y❑ N❑ Y ❑ N
Z) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mil is issued,I shall not employ any person in any manner Va as to
U become subject to the Workers'Compensation Laws of California.
Q i Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /�f f7`/
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
�.? emption,you should become subject to the Workers'Compensalion APPLIANCE 4.00 PLAN CHECK
provisions of Ilia Labor Code, you must forthwith comply with FEE
U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT.(TO 10=CF.M.) 3.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE d -
1 hereby arlirm 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(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
-� information is correct. I agree to comply with all city and countyPLUMBING
oNiumecs and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.)-4.00
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 purposes. _
(We) agree to save, indemnify and keep harmless the City of MISC. REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way acc a agmnIt City in consequence of the PERMIT ISSUANCE 3.00
MECH;CONT. LIC..NO.�
N0. TOTAL TOTAL /7
Signature of Applicant/Contras or Date
OFFICE COPY COPY