10034 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL'POINT,PEN ONLY
BUILDING PROJECT IDENTI FICATION PERMIT NUMBER
- ' • APPLICATION & PERMIT
BOLDING O O A
7(5S74, BUILDING- ELECTRICAL-PLUMBING-MECHANICAL L+
�J3VE aE
OWNER'S - r # 4, V;.a d y 9'Y d }N ,(+ +, q q,, PLAN CHECK VALIDATION
"AME a 3. ELECTRIC PERMIT d .+ '� ' "4FEEJP
PHONE' 4a ; KP}k# + 34r 2 {}
'NAMERACTOR's OUTLETS-SWITCHES''-RECEP 10,00/100 °
Lc.NO.• 339LIGHTING FIXTURES 10.00/1.00
CONTRACTORS' PPLIANCES-RESIDENTIAL 4.00
AOORESS
R_4PHONE55g-3131
PANELS . .10.00 DATE OF APPLICATION '
ORCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEERLIC.NO. SIGNS TRANS. 3,00
ARCH.OR ENO, PERMIT VALIDATION
AOORESs SPECIAL CIRCUIT - 5.00
nd TEMP.METER OR POLE INS. 20.00 �'►IY,
APPLICANT S
DDRESS
AMOTORS SEE FEE SCH. V
SERVICE CHANGE, 20.00 81985
w
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 {'p ppL{�
Q.i w I herebyafflrm that I am licensed under'provisions of Chapter 4 Of
CIJPA OWE DATE
'(commencing with Section 7000)of Division 3 of the Business and BLDG. EL L , PLG. MECH.
n i Professions Code,and my license is in full force and effect.' ❑ ❑
ow 0 License Class - e. umber -
Date Contractor
H LiN ..
rc a w
OWNER-BUILDER DECLARATION _ ' B I 'DING) ,ERMITV
oo. - - t4. ,iIN FORM TION',,.
fi
'xu ;,� N I hereby affirm that Lam exempt from the Contractor's License MISC.- REFER TO ORD -
FuoJ Law for thefollowingreason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00 'VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
Cimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC. i�
E, LL requires the applicant for Such permit to file a signed statement that TOTAL�.
n w E, he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the Ps ^: '";-s. z rI fTI
EE o Business and Professions Code)or that hell exempt therefrom and DTV:-'< AgT ''=PLUMBING,PERMUTW # FE€ &6, qf3dw
F the balsa for the alleged exemption.Any violation tof to action Permit
$ = a;,; - - _ ' '' ;r „ - - x N- p;-,�; �s B RIE T ECO R.
, a3 � by any applicant fora permit dollar,the applicanttOa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as - BACK FLOW PROTECT.DEVICE 4.00 oCC u E5 NITS
their sole compensation,will do the work,and the Structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves itler.OR,and who docs such work FIXTUR ES,PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedfor sale,If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 2.00
builder will have the burden of proving that he did not build or int - . - .
- BUILDING USE
prove for purpose of sole ❑ I❑ ❑N ❑ Other
Ell 1,
1,as owner of hpe property;am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec. 7044,Business LAWN SPR INKCERS- 1 INC 5'V.B. _ 6.00 ASSESSORS PARCEL NO.
coil Professmok Code:The Contractor's License Law does not apply
to an owner of property who builds,or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with o contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ I am exempt under Sec. ,B.&P.C.for this
reasoWATER HEATER W/VENT 6.00
n
Owner DateWATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a fertificato of consent to set Pinsunu, f _
or a certificate of Workers Compensation Insu ante,or a certified ZONING ENG.SITE NO.
wpy thereof fSec.38 o parry � ��� - - - -
Policy Na. - Company- 111���)
❑ Cetlifle c pY is hereby fr shed. - FIRE$PRINK ENERGY T¢4
' Z Z ❑ Certifie o y I Rled i I��,)th�@ �`Iy 1y+�pecrion division.
H O. Applicant LtL6. .J MISC. REFER TO ORD. ,Y ❑ N❑ Y ❑ N�
"En CERT CATEo EX PTION FROM WORKERS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
W > (This suction need not be completed Rif he permit is for one PLG.CONTR. LIC.NO. TOTAL /V Y❑ N Y N
ao
Z hundred dollars IS 100)or less.)
U O I certify that In the performance of the work for which this per-
LLF aGMECHANIACP•ERMIT stb "F#E°E R'4P FEEpSUMMA
mit is issued,I shall not em toy onY Person in any manne . d itVc.vf
°Ks'
+
Obecame subject to the Workers'Compensation Laws of Cal-
UJ
tL Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} Z NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F emption,you should become subject to the Workers'Compensation APPLIANCE , 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U 'FEE such provisions or his permit shall be deemed revoked, AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=CFM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) .5.00
the performance of the work for which this permit is Issued(Sec. - MICflOFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name Lender's Address I HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and State that the aho4e VENTILATION FAN (SINGLE) 4.00 -
• information is correct. I agree to comply with ell city and county PLUMBING'
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.Or1OO,000B.T.U.) 6.00
hereby authorite representatives ins of this city es coat upon the BOILER-COMP(Over 100,000 BTU)SEE FE E SCH. MECHANICAL'
above-mentioned property for inspection of
purposes,
(We) agree to save, indemnify and keep harmless the City of REFER TO ORD. - -
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit - MECH.CONT. LIC.NO.' MECH.
TOTAL `T.OTAL` ,
Slgnatureof Applicant/Contractor Date - -
OFFICE COPY