4926 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
BTU I LD ING PROJECT I DENTIF ON, PERMIT NUMBER
BUILDING - - APPLICATION & IT . 492.6
ADDRESS p. �
O BUILDING- '
-ELECTRICAL-PLUMBING -MECHANICAL
owNER's - -�- PLAN CHECK VALIDATION
NAME - CITY. ELECTRIC PERMIT _ FEE
NAME ME PHONE ,
RAcroRs OUTLETS-SWITCHES=RECEP 5.00/1.00
6rc%I JJa C_ uc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
�Es _ APPLIANCES-RESIDENTIAL 4.00
YY 66' J�pi.rc
PHONE /J (f•�To PANELS 5.00
Aoy '�
DATE OF APPLICATION
ARRCHITECT - SIGNS' 6.00 ' PLAN CHECK FEE P.C.NO.
NGINEER
LIC.NO SIGNS TRANS, 3.00
ADDRESS ENG' - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S J
AooREss ( MOTORS SEE FEE SCH. -
SERVICE CHANGE 10.00
w O o LICENSED CON'T'RACTORS DECLARATION
¢ U w I hereby affirm that I it, licensed miner Provisions of Chapter`JBSUANCE GATE
n a (commencing with Section 7000)of Division 3 of the Business and - L LECT. PLG. MECH.
F D i Professions Code d nse is in full force and effect ❑ ❑
zO i w 0 License Class Lic.Number _
F J Data Contractor FE 9J
F y
¢ 2 J
¢ ¢ w et OWNER-BUILDER DECLARATION B'INFORMATION IT
I'xa ; a N 1 hereby alfirm,that I am exempt from the Contractor's License misc.- REFER TO ORD Ci
H u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 X(rJ� S/FT.
ENA Code',Any city or county which requires a permit to construct,alter, U o�'0
Ic ¢ ¢0 improve,demolish,or repair tiny structure,prior to its issuance,also ELEC.CONTIT _ LIC.NC. ELEC.
eL iL m M requires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9lcommencing with Section 7000)of Divhsion3 of the - - R6�01�E�-.
Y s CI Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT + . t 'F,EE
R f the basis for the alleged exemption.Any violation of Section 7031,5 ` v . ;,/ y x STORIES TYPE CONSTR.
n3 _ by any applicant for a permit subjects the applicant to y civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not am.than five hundred dollars 15500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
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. 4.00
Corte:The Contractor's License Law docs 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. -
menusarenotintendedorofferedforsale.If,however.the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4,00
or improvement is sold within one year of completion, the owner - GAS-EA.SYSTEM-OVER 4 (EA.) 7.00 BUILDING USE
builder will have the burden or proving that he did not build or int-
' prove let purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ C3 1:1 ❑
licensed contractors to emutrucu 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 does not apply
to an owner of property who builds or ini,roves thereon,and who LAWN'SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)l wrowd puoumnt n
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
. ❑ I am exempt under Sc.-,B.&P.C.for this WATER HEATER W/VENT q,Op -
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION UECLARA'I'ION WATER TREATING EQUIP. 4.00
1 hereby affirm that I"have a certificate ofec nscm to self-insure,
or'a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy lhcrcof(Sec.3800,Lah.C.).
Policy No. Company
Jy - ❑ Certified copyIs h f fished.
Z i�i�i� ❑ Certified op Icy.11 I `cY .division. FIRESPRINK ENERGY T"24
O Applicant_ v�L, A yQ.b MISC.- REFER TO ORD. Y [:] N❑ Y ❑ N0
CC y CE RTI I'I CATE OF EXEMPTION PROM WORSE RS' PERMIT ISSUANCE -- 6.00 .FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE , PLG.CONTH. LIC.NO. PLG,
CL 2 (This section need not be completed if the Permit is for one TOTAL Y❑ Al Y C] NC]
hundred dollar,IS 100)a,less.) ,
L) O 1 certify that in the performance of the work for which this per TY. MECHANICAL PERMIT=+`. FEE r" " 'FEE SUMMARY', P
Ll: 1- mit is Issued,I shall not employ any pernm in any manner so as to r ` -
O become subject to lire Workers'Compensation Laws of California. n g�J1
d Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING O/U
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. 2 emption,you should become subject to the Workers'Conpensalion APPLIANCE 4.00 PLAN CHECK -
Provisions of the Labor Code, yotrmust forthwith comply with FEE
C� 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 fur 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 Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address " ELECTRIC
_7,;h^pF4, �., I certify that I hove read This application and state That the shove VENTILATION FAN (SINGLE) 3.00
mfonna]ion is correct I agree to comply with all city and county - PLUMBING ,
b'Ninances and stale haws relauing.to building connructian. and BOILER-COMP(3H.P.or 100,000B.T.U.) 4.00
hevcby authorize representatives of this city to enter upon the BOILER-COMP (OVar 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 and expenses which CONST.TAX
may in any way acne,agai t said City in consequence of the PERMIT ISSUANCE 3.00
granting of pe i . MECH.CONT, LIC,NO. MECH, r/
P�,G tS��'�J f TOTAL TOTAL � �I d 40
w eof Appliwn[/ 'onlnmlor: Date
OFFICE COPY