5586 •APPLICANT•TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FIC PERMIT NUMBER
RUIL.INGI - APPLICATION & PEWIT 5586
-� Ro,Nofless
GN fl , i
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NANtE PLAN CHECK VALIDATION
• �_47e I( IL .ONE 2jT, -` CITY, ELECTRIC PERMIT FEE
.NTflacT.fls UTLETS-SWITCHES-RECEP 5.00/1.00
NI
.gC1-UG. 4flL SrO16/` uc.No.3 6yf^ LIGHTING FIXTURES 5.00/1.00 '
ADORE7 ACTOfl'S ,
AooflEss APPLIANCES RESIDENTIAL 4.00
D -Q •Zt '�Lr`' PHONE 7I 'O L(970 PANELS .5.00
GATE OF APPLICATION
ARCHITECT
OR SIGNS . 6 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG.
ADDRESS - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
APPLICANT'S
TIP EMP.METER OR POLE INS. 15.00 ( J
AooflEss MOTORS SEE FEE SCH.
SERVICE CHANGE - 10.00 '�/
F
00 LICENSED CON'T'RACTORS DECLARATION G��
e,in u ISSUANCE DATE
I hereby affirm that I am licensed under provisions of Chapter 9
y Q m (commencing with Section 7000)of Division 3 Of the tlusineis and BLDG. ELECT. PLG. MECH.
F Dw Professions Code,and my license is in full to,,4� d ffRcy. "
zO z rn w imnsgClass_ Lic.Number-
t:
umber
H S Y p YJ ❑ ❑ ❑ ❑
. w J Dalc_/'T 6�) Contrac[or,.,{•C 7' /N_-_}'i! I,; ,
a " J BUILDING PERMIT'.
m w< OWNER-BUILDER DECLARATION -
w3 LL w I hereby affirm that I am exempt from the Contractor's License• M ISC.- REFER TO ORD INFORMATION
. u o j Law for the following reason,(Sec.7031.5,Business and professions �/yLyg�ION $/FT.
Code:Any city.,county which requires a permit to construct,alter, PERMIT ISSUANCE 6.00 T�+v4J}yQ]
m 2< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UC.NO. ELEC. /
i -CLL - he
vires the applicant for such permit to file a signed actor's i that TOTAL 1�d r814TO
Le ro he is licensed pursuant to the provisions of the Contractor's License L / � `i ,V'1�-,
H i'Q Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE `�-2.� f7e" 7
T r es the basis for the alleged exemption,Any violation of Section 7031.5 $f pr $, T PE CONSTR.
n3 � by any applieani for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.14.00 Ity V' y�PertlO
of not more than five hundred dollars($500).1'
❑ I,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 (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law does not apply 10 an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
, 7. meats are not intended or offered for sale.I L however,the building GAS-EA.SYSTEM-l'INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner.
build"will have the burden of proving that he did not build or fill- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting 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 does not apply . .
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 _ TRACT NO. PARCEL NO.
❑ 1.m exempt minder Sec. ,B.&P.0 for Ibis WATER HEATER W/VENT 4.00
mason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. rPAJU.00
[ hereby affirm that I have a certificate ofconsent to self-insure,
or a certil fete of Workers'Ccmpensa n In ,or a certified ZONING ENG.SITE NO.
�p 9u yp
copy thereof lSec.38mab(:J. w
Policy Na CoCompany
O ❑ Certified copyishereby funis edQ{.t FIRESPRINK ENERGY T-24
Z 2 ❑ Certified y is filed with the ci�ty,�in pecnon division. �'IYII
FO " Applicant16 /' mp�Aaa�/,^.4 MISC.- B Y0 N❑ ,Y ❑ N[]
PERMIT ISSUANCE
LUN CF.RTIFICAMPENSATIONEXEMPTIONNS FROM WORKERS' 6.00 i FLOODZONE ALU C.
W� 0 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �
(This section need not be completed if the permit is for one - TOTAL//O ( Y 0 NE] Y 0 N❑
:3O hundred dollar,($100)or less.)
1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
IL F- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Warkers'Compered ion Laws of California.
y Date ,Applicant ALTEROR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of F,x- l�
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVERIOPMC.F.M.) 5.00 SEISMIC FEE
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.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
1 certify 11,411 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 !�
information is correct. I agree to comply with all city and county PLUMBING �jO v'
• ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives forms inspection
this city to enter upon the BOILER-COMP (0.,100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
above-mentioned property forinsp of t1, 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 accrue against said City in consequence of the PERMIT ISSUANCE3.00
yp
gmntinlhis permit MECH.CONT: LIC.NO. MECH.
TOTAL
�I/Y//n �(�dfA�2 TOTAL �Pl
Signature of Applicant/Contractor Date
OFFICE COPY