3919 (2) APPLICANT,TO FILL IN-INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�,. BU I LDING PROJECT I DENT]FICATI ON PE MIT NUMBER
BUILDING APPLICATION & PERMIT
\4 ADDRESS
Ui•Q j� D 1'a i\ e AVBUILDING -ELECTRICAL-PLUMBING-MECHANI L 3919
OWNER'S - 1 4 -Vr�0h Q QJ PLAN CHECK VALIDATION
NAIMMTE y� (' PHONE u/LV3-0gua(/�/ OTY; - ELECTRIC t PERMIT FEE
hi `
ERACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00 '
ADDDRESSTDR'B PPLIANCES-RESIDENTIAL 4.00 ,
PHONE PANELS 5.00 DATE OF APPLICATION
OR
RCHITECT SIGNS 6.00 PLAN CHECK FEE P.D.NO.
ENGINEER
UC.No, SIGNS TRANS. 3.00 - -
ARCREssENG' SPECIALCIRCUIT S.00 PER MIT VA LIGATION
I
zIPfTEMP.METER OR POLE INS. 15.00
APPLICANT MOTORS SEE FEE SCH.
A
SERVICE CHANGE pq 10.00 . 7/�
ca �T
w o -LICENSED CONTRACTORS DECLARATION 3
U,u 1 hereby affirm that I am licensed under provisions of Chapter 9JUU
ISSUANCE DATE
N1° Icummencing with Section 7000)of Division 3 of the Business and
N C n BLDG. ELECT. PLG. MECH.
r w i Professions Code,and my license is in full force and effect. - .y ❑ ❑ ❑
z,n License Class Lia Number C]ty Of C(1pe1 lIOO
m I- w Dule Contractor
BUILDING PERMIT
Ic w u OWNER-BUILDF,R DECLARATION
CO MISC.- REFER TO ORD INFORMATION
II� g e w I hereby affirm that I am exempt from the Contractor's License
Fu04 Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 vnwnTlON S/FT.
N � Code:Any city or county which requires a permit to construct,alter,
a 2 ¢° improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. -LIC.NO. ELEC.
U, N0 ir requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
0. he is licensed pursuant to the provisions of the Contractor's License
r z Q
Law(Chapter 9(commencingwllll Section 700()of Division Solthe �C'L,tr[J7
F 4 ° Business and Professions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE
SER $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
,w by any applicant for a permit subjects the applicmv to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five.hundred dollars(4500).):
❑ 1,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 the 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 docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SD.FT,FLOOR AREA TOTAL ACREAGE
IDate
himself Gr through his own employees,provided that such improve
its are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
mprovement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
iler will have the burden ofProving that he did not build or im- RES IND eNG PB Omer
ve for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RE ❑ ❑ �I,as owner of the property,am exclusively contracting withnsed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 AMESSORSPARCEL NO.
Professions Code:The Contractor's License Law does not applyn owner of property who builds or improves thereon,unit who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tracts for such projects wiBl a contractoos)licensed pursuant to 'Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
lam exempt under Sec. B.&P.C.1or this WATER HEATER W/VENT 4.00
er WATER SYSTEM 4.00 ACC,GATE ACC.FILE NO.
WO R K Ii RS'CO M PE NSATION DECLARATION WATER TREATING EQUIP. 4.00
.1
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.'
copy thereof(Sea 3800,I.A.C.).
Policy No. - Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑APPIIcCertified
ant Certified copy ii`tiled with the city inspection division. MISC.- REFER TO ORD. Y N V ❑
N
CERTIFICATE E EXEMPTION FROM WONKIiRs' PERMIT ISSUANCE 6.00
FLOOD ZONE A.L.U.C.
W > COPNSATDN INSURANCE
PLG.CONTR. LIC.NO. PLG.
'd o (This section need not be completed if the permit is for one TOTAL Y❑ IN Y ❑ N�
D Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
- W 1- mit is issued,1 shall not employ any person in any manner so its to
U W become subject to the Workers'Compensation Laws of California.
Dart Applicant BUILDING
a pp ALTER OR ADD TO MECH. 4.00
} W NOTICE TO'APPLICANT: If,after making this Certificate of Ex-
F Z emption,you Should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1,hereby affirm that there is u constRetinn 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 HEATING UN IT 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state Ilial the above VENTILATION FAN (SINGLE) 3.00
I`,nformation is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
finances-and state laws relating to building construction, and
'by amjio"z, representatives of this city to enter upon the BOILER-COMP IDVs,�100,000 BTUI SEE FEESCH. MECHANICAL
,156vementioned properly 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue a• 'nst said City in consequence of tine
anti Borth permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
gtmture of Applicant/Contractor Date -
OFFICE COPY