7069 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[F I CATION PERMIT NUMBER .
BUILDING APPLICATION & PERMIT
Aoo .ss nor 4
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 7069
OWNER'S PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
CONTRACTORS { ,` I�D t
OUTLETS-SWITCHEERECEP I%5.00/1.00
I LIGHTING FIXTURES 5.00/1.00
.oNTRAcions PPLIANCES'-RESIDENTIAL 4.00
11 ZGRES
r C' P-ON _ PANELS 5.00 DATE OF APPLICATION
RCIIIT"Ci SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.No, SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
BIP EMP.METER OR POLE INS. 15.00 e I
APPLICANT s MOTORS SEE FEE SCH.
REb �M ^m
SERVICE CHANGE 10.00
o O LICENSED CONTRACTORS DECLARATION v
< u I h r 1 y uUi m that I no licensed add,,provisions of Chapter 9 - - _ ISSUANCE DATE
H < (c I I IIL 6 w th S bon 7000) Division 3 of It B ince,mtd BLDG- ELECT. PLG. MECH.
s r z P Nessl n Lod nd I liana n full fore fl I .e' 1 I E- ❑ - •❑
,'0 m L u.nw Class c N n - -
o y H w Daae-I tr�tor _ 1 -
st YlZ - BUILDING PERMIT
re a, w OWNER-BUILDER.DECLARATION INFORMATION
E o A REFER TO ORD
uLL r I hereby affirm that I an exempt from the Contractor's License MISC.-
.. o¢ Law for the following rcuson.(.Sec.7031.5,Business and Professions 'PERMIT ISSUANCE VALUATION
� -
Code:Any t or which requires Font to construct.alter, 6.00
city w Pe
QQ 4 p Ilnp(t)VC,dt'mfII1SM1,Or repair any ilrOCtnlC,prior to its Isinanel'.aI50 ELEC.CONTR. LIC.NQ ELEC.
A o u requires(lie applicant for such permit to file a signed statement that TOTAL PERMIT TO `
u w m w he is licensed pursuant to the provisions of the Contractor's License
,Z > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
< Business and Professions Code)or that he is Exempt therefrom and OTY. PLUMBING PERMIT FEE
E'i o
¢ ;- the basis for the alleged exemption.Any violation of Sect ion 7071.5 - STORIn TYPE CONSTR.
by any applicant fora permit subjects the applicant to a civil pendlty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole eumpensation,will do the work,and the structureis not OCC.GROUP RES.OBITS
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 or Im;Bovo II1eR011,and who does such work FIXTURES-PER TRAP - 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employeesFprovided that such nflo ve-
menuarenotintended or offered for sale.It,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
R S IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ Las owner of tire property,am exclusively contracting with ❑ ❑ E) El
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
mvl Prol'e,,iuns Code:The Contractor's License Law does not apply
to un owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '•
contracts for such projects with a contractor(')licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.(or this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hemby affirm that I have a certificate of consent to se Batinsure. ZONING ENG.SITE NO.
or a certificate of Workers'Compen 'tion Insuran e�or a cern ed
copy
q I 38 00,�.,Ib C).
O Polm1j2C0.w
[1 crNHc Item I' vd. _ FIRESPRINK - ENERGYT-24
z. m}G .. .� .. .. _ Y, .,a,a d.
'ZO` '• AI I_ rI f MISC sl REFER-TO ORD;, .'V Y" -No N❑.
M N CLR'I'IFICArE OI'EXEMPTION'('ROM WORKERS' I PERMIT ISSUANCE 6.00 PLOODZONE Al u.C.
W > COMPENSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG YE]
N❑ YE] NE]
O ('Fiji, seetio need not be Completed if the permit is for one TOTAL
Z hundred dollars lSl001 or less.) _
O O 1 certily that in the perforn:mce of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers Compensation Laws of California.
O w Darc A licaot BUILDING I
a pp ALTER OR ADD TO MECH. 4.00
> m NOIICE 1'O APPLICANT: If,after making this Certificate ser ion
F ? emvision you should eLbecome subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10.000GF.M.) 3.00
CONSTRUC"FION LENDING,AGENCY AIR HANDLING UNIT(OVER 10SWC.F.M.) 5.00 SEISMIC FEE t
I hereby affirm that there is a construction lending agency for A EXHAUST HOOD.(WITH DUCT)-s 2.00
the pertinmance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lendelh Name
HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Name ELECTRIC
I certify that I have read this application and state t/tai 010 above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all 1Iy,und,eounty PLUMBING
ordinances and state laws relaBOIL'ER=COMP(3 H.P.or 100,0008.T.U.) 4.00
ting to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,0008TU)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 g ' sl liabilities,judgmcnis,.ensis an expenses which O CONST.TAX
r'
may in'a a ay accru' ;Ia,saiit City in sequence of the PERMIT ISSUANCE 3.00
grant this per 1 MECH.CONT. LIC.NO. MECH.
( l% TOTAL TOTAL
Signature of Applicant/Contractor Date
INSPECTOR COPY