5055 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES - USE-BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON - PERMIT NUMBER
BUILDING. APPLICATION & PERMIT
ADD B _ _ 5055
� y�Jj /3AND(,p -p R •BUILDING - ELECTRICAL-PLUMBING-MECHANICAL °
OWNER'S it^, # Sw PLAN CHECK VALIDATION
NAME M UT DTV: 'ELECTRIC PERMIT` FEE[`,
wONTRACTORS " 3 QOUTLETS-SWITCHES-RECEP 5.00/1.00
.� NAME " : .'. • - �/
/U rTe�-O �.�QC71fjQic.rvo. .7
.2CALIGHTING FIXTURES 5.00/1.00' -
foNTRAC> ADDRESSTOR's. -' a APPLIANCES-RESIDENTIAL, 4.00
OX 6 /11 N7.upilii NE //FlpIIv_:�SY3 PANELS '5.00 'DATE OF APPLICATION.
' ARCHITECT SIGNS .' 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER 1710 Ne. _ r
'v DID,No. ... SIGNS TRANS: 3.00
ARCH.OR ENG. r PERMIT VALIDATION
ADDRESS " N e 'I' - ' SPECIALCIRCUIT -5.00
N, 01 rip EMP. METER OR POLE INS. 15.00
APPLICANTS
GRES5 TS ' • MOTORS loWC- / EE FEE SCH.
.a ,(SOX p.36 h'INT•vvf Aj SERVICE CHANGE. 10.00 ° ,Y/ 1��,/
0 o o LICENSED CONTRACTORS DECLARATION •� b'r� - •/
¢ v v 'I hereby affirm that I am licemed•hnder provisic�nv of Chapter'9 - ISSUANCE DATE
y a Iw (commencing with Section 7000)oD Division 3 of the Business and -
BLDG. ELECT. PLG: MECH.
H o 2• Professions Code and tvJ"o L1 1
1 IN, full for •aI d •f CI� f` �.{,, t
z o w •Licen a CIf s iJ L¢ Numbel1 �� ��er lulu ❑ ❑ ❑
o H w Date,vCon(ruclor
¢ se s I.r BUILDI NG PERMIT ;.r<',:
¢ o d D OWNER,BUILDER DECLARATION �ya H a<INF.ORMATION" '>
1 hereby affirm that I am exempt from the Contractor's License'[ MISC.- REFER TO ORD
m VALUATION $/FT:
Fu0¢ Law for the following reason(Sec.7031.5,Business Professions pERMIT ISSUANCE 6.00
60 IOU
Code:Any city or county which requires a permit to construct,alter, -
s- ELEC.CONTR. LIG NO.
Q.0 improve, or repair any structure,prior to its issuance,also ELEC.
F m¢ requires the applicant for such permit l0 file a Signed statement that TOTAL - PERMIT TO-
w `
n w he is licensed pursuant to the provisions of the Contractor's.License ,. ° _ - LAG O
Law 9(commenciagwith Section 7000)of Division 3 office "'<' ` -
Q + 3„
4 0 Business and Professions Code)or that he is exempt therefrom and QT-V. ' PLUMB ING"PERMIT-- i
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 -. '* ' - < .`-'+ - '. STORIES TYPE CONSTR.
In
3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not nmre than five hundred dollars(5500).): -
❑ 1,as owner ofdhe 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
Code:The Contractor's License Law does not apply to an owner of
properly who builds or'improves thereon,and who does such work FIXTURES-PER TRAP 4.00
SO.ET.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such
improve-meats are notimended or offered for sale.If,however,the building, GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
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.
prove for purpose of sale.). INDUSTRIAL WASTE INTER: 2000
❑-1,as owner,of the property,am exclusively contracting with . E] ❑ E] ,[-] ❑
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 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 a conlractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/6.00 the Contractor's License Law. - TRACT NO. PARCEL NO.
. ❑ I am exempt under Sec. B,&P.C.for this WATER HEATER W/VENT 4100
•reason
Date - Owner _ WATER.SYSTEM 4.00
ACG DATE - ACC.FILE NO.
WORKERS-COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00 -
- I hereby affirm that I have'a certificate of consent to sell insure,
-
or acertificate of Workers'Compensation Insurance,or a certifieA ZONING ENG.SITE NO.
copy thereof(Sec 3800,L.bC 1 -
Policy No. - Company _
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z. .er crtifle is fled ev the` ity'CpP�P yyt n divisi n MISC:- REFER TO ORD.
Q 'Applicant LhYd.� Y ❑ N❑ v ❑ N❑
H w - I . PERMIT ISSUANCE 6.00
Lu CERTIFICATE E EXEMPTION FROM WORKERS''" FLOOD ZONE A.L.U.C.
W � COMPENSATION INSURANCE. " ' PLG. PERMIT
LIC.NO.. .PLG. -
�
0( This acetum need not Ike copleted If the"permit is for one TOTAL Y❑ N❑ - v ❑ N❑
hundreddollars(5100)or less, m ..' -
O 1 certify that in the performance of the work for,whieh this per- TY. MECHANICAL PERMIT - .'FEE - FE'E SUMMARY
LL' I- mit is issued,I shell not employ any person in any manner so as to - -
Wbecome subject m file Worked'Compensation Laws of California.
SID Date Applicant - ALTER OR ADD TO MECH. 4,00 BUILDING'. . '
} m NOTICE TO APPLICANT: If,after making this Cerlificate of Ex- -
� Z eruption,you should become subject to theWorkers Compensation ' APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
r CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is-a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
theperformance of the work-for which this permit is issued(Sec. MICROFILM .
3097,Civ.CA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT, 100:000 B.T.U.)7.50 �y
Lender's Address ELECTRIC V O Ste`
- Icertify'that Ihave read this application and state hart"o above N ENTIL_AT_ ION FAN (SINGLE) -3.00
information is correct. 1 agree to comply with all city and county PLUMBING
• ordinances and state laws relating to building construction, and BOILER-COMP(3 H:P.of 100,0006.T.U.) 4.00 _
hereby authorize r perry lives of this city to enter.upon the BOILER-COMP`IOver 100,000 BTU)SEE FEE SCH. MECHANICAL'
above-mentioned property for inspection purposes. "
(We) agree to save, Indemnify and keep h tonne s,the City of _.'MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costa and expenses which PERMIT ISSUANCE - 3.00 CONST.TAX '
may in any way accrue against said City in consequence of the
granting of this permit • MECH.CONT. LIC.NO. MECH. - F
M�rf/ �I .2 .27-. TOTAL TOTAL
SlRnalure of Applicant/Contractor Date- "-, - r
OFFICE COPY- - -