7268 g r'A4LICANT TO FILL IN INFORMATION WITHIN RED LINES'-'USE BALLPOINT PEN ONLY.'BU I LDI NG PROJECT I DENTI FICATION, PERMIT NUMBER
BmLDING. APPLICATION•& PERMIT - ^/1/�
ADDHEss /6){
d / BUILDING ELECTRICAL-PLUMBING-MECHANICAL 268
LO 4 '&'+ x y P �Ho VALIDATION
"AMEOvVNERs (1( ,G '" QTY`p.� y VLiEIECTR CP.ERMIT Oft
FEE Lfp
S -ONE 'f • -y \.v `4.`"n -:f't u"..t..'-.b4 51y.
GONTIIACTOHs DUTLETS-SWITCHES-RECEP 5.00/100 '� D
NAME 8s
"uc.No.33�J! LIGHTI NG FS
IXTU RES 5.00/1.OQ
r.Orv7Rnc7ola PPLIANCES,-RESIDENTIAL 4.00
ADORES
S PRDNE PANELS 5.00 DATE OF APPLICATION
ARCHITEC SIGNS �y B.00 , PLAN CHECK FEE
OR
ENGINEER 3.00
"C.No, SIGNS TRANS.- '
ARCH.OR ENG. .5.00 PERMIT VALIDATION
'ADDRESS _ SPECIAL CIRCUIT _
ZIP EMP.METER OR POLE INS. 15.00
.APPLICANTS -.v MOTORS - SEE FEE SCH. 1-3
. ADDRESS ,.. .
SERVICE CHANGE 10.00
PA af-
.woo. LICENSED CONTRACTORS DECLARATION •+
a o u I hereby affirm that I am licensed under provislona of Chapter S) I CE DATE
a H (C
h ommencing with Section 7000)of Division 3 of the Business a d E PLG. MECH.
r w z Professions Code,aA my license is in full for fe- , A ❑ s❑ ❑
z o m- Licensl�la� Lw.Number ^'
o r w Contractor lait
G PERMIT
a j
¢ y¢w OWNER-BUILDER DECL A'r1ON INFORMATION
K
;LL H I hereby affirm that I am exempt from the Contactor%License MISC.- REFER TO ORD -
VALUATION S/FT:
a Law for the following reason.(Sec.703 L5,Business and Profeasions PERMIT ISSUANCE 6.00 0)��
� ,,,�� Code:Anyeily orcounty which requires a permit to construct,alter, ELEC.CONTR. LIC.NO. -
ne a 4 o improve,demolish,or repair any structure,print to its issuance,also ELEC.
DLL requires the applicant for such permit to file a signed statement that • TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License -�
Law(Chapter 9(commencing with Section 7000)ofDivision 3 uftle �`�N
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
P o
¢r$ the basis for the alleged exemption.Any violation of Section 703 LSTORIES TYPE C STP.S ,
T by any applicant for a permit subjects the applicant to a civil penalty ENT-WATER (EA.) 4.00 -' . /
oALTER-DRAIN&V
f not more than five hundred dollars(SS00)J: �A/, C
-
Ll 1,as owner of the property,or,my employees with wages as stBACK FLOW PROTECT..DEVICE 2,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the ructure is not q
intended of offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 �.J
Code:The Contractor's License Law does not apply to an owner of -
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that Such improve. GAS 4.00 31
mre '
mems are not intended or offed for sale.IL however,the building -
or improvement 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- RES IND CON PB Omer
pruvefor purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00
❑ [,as owner of the property,am exclusively contr:¢ting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cont - - '
conacts for such projects with a cuntructons)licensed pursuant tO
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4,00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy therenl'ISec.3S00,Lab.C. /F- /T =Z- ,y^/ 3
Policy No. Cmnnda y , (--
O O Certifie pY la horebyl hCJ. FIRESPRINK ENERGY T-24
Z 2 ❑ Cetlifi• c is file) Itl -it i s ctim division. . . V N V N
O Applicant ` ,��.� MISC..- � REFER TO OR D. ❑ ❑ ❑ ❑
I- ' PERMIT ISSUANCE - 6.00 FLOOD ZONE A.LLLL.
1 CfiRl' 'AT'1 OF 'XP 'ION FROM WORKERS'
_ COMPENSAI NINSURANCE PLG.CONTR. LIC.NO. PLG.
CL O fI'hix set urn need tint be completed if the permit is for mhe 'TOTAL Y•❑ N❑ Y ❑ N❑
�.2 hundreddollms($10()orless) q"+ aw�.F.,�' p, •y" ,
U O and Is issued1 certify , ltsin lmllthnot performance
of thework
lnr,nornwal^nhrtso15as rn QTVaAMECHANICALaNPERMIT FE�E�}''� FEE SUMMARY
F employ y pc Yh � .. 4'f' �`'•. xes
U' hecmne subject to the Worker%Compensation Laws of California. 'y
w Dale Applicant ALTER OR ADD TO MECH. ` q-00 BUILDING 733 t--
},N NOTICE TO APPLICANT: If,diter making this Certificate pf,H,s
-H' ? emplion,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.IA) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 45- Ls
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.L .HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's AddHEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
ress
• Icert ify that l have read t his applicat ion and state that the above VENTILATION FAN (SINGLE) 3:00
ton '
ination k correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building conslrletion, no BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
heu.,by authorize representatives of this city to enter upon the BOILER-COMP tover 100,000 BTO)SEE FEE SCH. .MECHANICAL
above-mentioned property for inspection purpnus.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may any way acc,re against said City in consequence of the PERMIT ISSUANCE, 3.00
gr lin of this per ` MECH:CONT. •LIG NO. MECH.
TOTAL TOTAL .'. 7�
S1 time of tic Contractor de Date -
'OFFICECOPY -