1051 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL
BU ILDING PROJECT I DENT[FICATI ON PEM UMBER
eo "DaNc
ADDRESS APPLICATION & PERMIT 10 51 -
RESs
.3 tdtV O G BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE'
PHONE 44 pilo 3 -
CONTRACTOR'S
rvaME T OUTLETS-SWITCHES-RECEP 5.00/1.00
�� l LIc.no 2PIAMS LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS APPLIANCES-RESIDENTIAL 4.00
1
O1.O CAtJT s PHONE S ' PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.DD PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCH OR
DDRESS ENG. ' SPECIAL CIRCUIT 5,00 ,� PERMIT VALIDATION
z;v TEMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
ADDRESS pRE55
SERVICE CHANGE 10.00
w o O LICENSED CONTRACTORS DECLARATION
rt U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w<n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z Professions Code,and my license is in full for�g a d�_el'I'�014 7 ❑ ❑ ❑
z o m - License Class _ Lia Number��+
9 0 r Date Contractor f
a Y4 -�+ BUILDING PERMIT
It as OWNER-BUILDER DECLARATION -
A o a u '-INFORMATIONS
wI- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F 3 0¢ Law for the following reason.(Sea 7031.5.Businessand Professions pERMIT ISSUANCE 6 00 VALUATION $)FT.
Code'.Any city or county which requires a permit to construct,alter,
EE2 G p improve,demolish,or repair any structure,prior to its issuance,also FLED.CONTE. LIC.NO. ELECrc . i
E 0 u requires the applicant for such permit to file a signed statement that OW16/�� T t. ` TOTAL PERMIT TO
,e m m he is licensed pursuant 10 the provisions of the Contractor',License _
rzr
Law(Chapter 9 fcommencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
i ; m by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.)of not more than five hundred dollars(S500).1: . -
❑ I,as than
of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their Sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale fSec. 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 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-
merits are not intended or offered for sale.If,however,the building GAS-EA.S EM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SV -OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or iin- RES IND CON PB Omer
prove for purpose ofsale.). INDUSTRGigL WAST TER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRI KL RS- 1 V.B. 5.00 ASSESSORS PAHCEL NO.
aEd Professions Code.The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS V E EA.) 1.00
contracts for such projects with a conlraelods)licensed pursuant to
the Contractor's License Law. SEWER-S ARV-S EA. 200ft/8.00 TRACT No. PARCEL No.
❑ I am exempt under Sec. ,B.&BC.for this WATER HEA W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKE.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a cettif KaZONING te of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sew 3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z ❑ Certified o fit d with the city inspersion Aivision.
Z AtoheanY �j y� - MISC.- REFER TO ORD. Y ❑ N❑ Y N❑
= W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLCODZONE A.L.U.C.
Lu COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d ❑ ❑ Y NE]0 (This section need not be completed if the permit is for one TOTAL vN
D Z hundred dollars IS 100)or Tess.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
. I- 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 be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm 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.E HEATING UNIT(TO 100,000 B.T.U.) 4.00 _
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
1 certify thin I have read this application and statethat the ubove VENTILATION FAN (SINGLE) 3.00
information correct 1 agree tcomply with nd county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.7.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 rind expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gr tin of t permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
g ature of Applicant/Contractor Date
OFFICE COPY