7252 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT(FICAT ON PERMIT NUMBER
BDILOirvG APPLICATION & PERMIT 7252
ADDREss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• orvE
NOO(MIERAL,eit UTLETS-SWITCHES-RECEP 5.00/1,00
{- LIGHTING FIXTURES 5.00/1.00
ADDDRESSRESS OR
r,Ds PPLIANCES-RESIDENTIAL 4.00
/�
1 Sete PHONE 311 (J� PANELS 5.00 DATE OF APPLICATION
ARLRITECi SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
00'Ess ENa SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
AGDAESS rs MOTORS SEE FEE SCH.
AooRes (�
SERVICE CHANGE 10.00 ,,,•)
w02 LICENSED CON'rRACfORS DECLARATION
¢ vu I hereby affirm that 1 am licensed under provisions of Chapter') ISSUANCE DATE
w
P, (commencing with Section 7000)of Division 3 of the Business and
¢H BLDG. ELECT. PLG. MECH.
r y z Professions Cod•,and m license is in full force and effect. ❑ ❑ ❑
z O m- License C ss Lie.Number
9 r w Date Cnntrudur�...r-/.
BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION'.'-
oAU MISC.- REFER TO ORD
X
3 o y I hereby affirm that I am exenhpt from the Contactors License VALUATION $/FT.
F .. o ¢ Law for the fallowing reason.(Sec.703 L5,Business and Profscours PERMIT ISSUANCE 6.00
Code Any city or county which requires a permit to construct.alter,
a, ¢Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
K e u requires the applicant for such permit to Nle a signed statement that TOTAL PERMIT TO
A w m y he is licensed pursuant to the provisions of the Contractor's License
,- zQ law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE lT
¢ moo the basis(or the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
d ;m by any applicant for a permit subjects the applicant loacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compens tiou,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProPoSsinns DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code;'rhe Contractor's License Law does not apply to an owner of /y
propertywhobuilds or improves thereon,and who does such work FIXTURES-,PER TRAP 4.DD y SO.FT.FLOOR AREA TOTAL ACREAGE
himself o through his own employees,provided that such improve.•- recuts are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
r int pfovement 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. REB IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct DD, project(Sec. 71)44,Business LAWN SPRINKLERS- 1 INC 5 V.8. 5.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law dues not apply
to an owner of property 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.
Eltum exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
I
Owner Date WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
.WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I I hereby affirm that I have a certificate ife.asect to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,LAC.).
Policy No Company
0 ❑ Certified copy is hereby furnished FIRESPRINK ENERGY T 24
zZ 0 Certified copy is filed with the city inspection division. MISC.- I REFER TO ORD.
O Applicant v❑ N❑ v ❑ NE)CCN CERTIFICATE 017 EXEMI'1ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU.C.
LLI > COk11'ENSATION INSURANCE PLG.CONTR. LIC.N0. PLG, CY
Z ❑ N❑ Y E] NE]1'I'his section need not be completed if the permit is for one TOTAL
hundred dolters(SI00)or less.)
U O 1 erRify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY+« "
LL f mit is issued,I shall not employ any person in any manner o a
U become subject m the Workers' ' atiolLhv of Ii r
a Date Applicant ALTER OR ADD TO MECH. q,Qp BUILDING
} to NO'I-IC17'10 APPLICANT: If,after making the,Certificate of Ex-
F Z empliun,you should become subject to the Workeri 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
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency I'or 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 NamHEATING UNIT IOV ER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws elating Dr building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby. authorize represenlalives of this city to enter upon the BOILER-COMP (Over 100,0008TU)SEE FEE SCH. MECHANICAL
above mentioned property I'or inspcaian purposes.
(We) :gree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERM IT ISSUANCE 3.00 CONST.TAX
Duty in any way accrue against said City in consequence of De
gr fit t Is permhl. / MECH.CONT. LIC.NO. MECH.
X2/7/ `- ,Ldp-rte TOTAL TOTAL
,Wiener of Ap�l/Contras r Date
INSPECTOR COPY