4356 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTIFICATI ON - - .- PERMIT NUMBER
-�( BUILDING APPLICATION & PERMIT. : 4.3 J 6
/ ADDRESS - `i• J U
/ OQO �` CL(.E rT UILDING -�ELECTRICA L-PLUMBING-MECHANICAL '
71 OWNER'S PLAN CHECK VALIDATION
NAME -
QTY. ELECTRIC PERMIT FEE
MAKJEANe E ONE �S I
CT -
f' CONTE OR'S
ISl-
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 •I
LIC NO. LIGHTING FIXTURES 5.00/1.00 '
ADDRESSTORS - APPLIANCES-RESIDENTIAL 4.00 -
PHONE PANELS 5.00 DATE OF APPLICATION.
ARCHITECT - SIGNS 6.00 - PLAN CHECK FEE P.C.NO.
ENGINEER• -
LIC NO: - SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT : 5.00 - �.
' - ZIP TEMP.'METER OR POLE INS. 15.00 •.
APPLICANT S
ADDRESS
- MOTORS- - ' SEE FEE SCH: '
SERVICE CHANGE • 10.00 3/E d.
F o o LICENSED CONTRACTORS DECLARATION
F.i w 1 hereby affirm that I am licensed under provisions of Chapter 9 - - ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
w Q.y r BLDG. 'ELECT. PLG. MECH_
r m z Professions Code,and my license is in full force and effect.
o i w o License Class _ Lic.Number - - ❑
rw H j ate
DContractor
El
¢ ¢ w :r OWNER-BUILDER DECLARATION , - c ' BUILDING PERMIT
A.
0 c. - I hereby affirm that I am exempt from the C ntractor's License: MISC.- REFER TO ORD INFORMATION
_ - VALUATION _ $/FT.
HuOg Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
m�+ Code:Any city or county which requlresa permit to construct,alter, `
> ELEC.CONTE. LIC.NO. P
2 a <O improve,demolish{or repair any structure,prior to its issuance,also _ , ELEC.
or requires the applicant for such permit to file a signed statement that TOTAL
' a- is PERMIT Tp
m y he is licensed pursuant to the provisions of the Contractor's License -
p2> Law(Chapter 9.(commencing with Section 7000)of Division 3 ofthe
40, (.LF-
Business and Professions ode)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEEAr i6pi
' fi
¢ r.$ Code)
basis for the alleged exemption.Any violation of SectionJ031.S TORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty U4, 0J S 61eo,'
of not more than five hundred dollars(5500).): ALTER-DRAIN -WATER (EA.) 4.00 -44 of❑ 1,as owner of the property,or my employees with wages as - ,BACK FLOW PROTECT. DEVICE 2.00 c ouP. RES.a ITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sea 7044, Business and Professions .DRAINS-FLOOR,ROOF,AREA,COND. 4.00
` Code:The Contractor's License Law does not apply to an owner-of "
property'wfio•builds or improves thereon,and who does such work: FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
. � mems are of ugh intends ownemployees,for
Safe.If,ed however,the
improve- EA,SYSTEM-1 INC.4 OUTLETS 4.00
himself
are not intended or offered for sale.If,however,the building GAS
or improvement is sold within one year of completion, the owner- .GAS-EA.SYSTEM-OVER 4(EA.) j;00 'BuaDING USE
builder will have the burden of proving that he did not build or im- RES - IND CON ' PB Omer '
prove I-as.for act of sale.). INDUSTRIAL WASTE INTER. •20.00
.❑ L.as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed CDionsCtod:The Contractor's
project(Sec. lines Business LAWN SPRINKLERS-1 INC5 V.B. 5.00 • ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Lew does not apply to antr owner ouch projects
who builds r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) '9.00'
contracts ctor'sh projects with o confruaor(s)dicensed pursuant to -
' the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. BA P.C.for thisWATER HEATER W/VENT 4,00'
., reason '.
- Dare - 2 Q Owner•144pd? WATER.SYSTEM 4.00, ACC.DATE, ACC.FILE NO.,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 f
1 hereby affirm that 1 have a certificate of consent to self-insure, - _ ZONING 'ENG.SITE No-
or a certificate of Workers'Compensation Insurance,or a certified ,
' copy thereof(Sec.3800,Lab C.).
Policy No. ' r company'- " -
. ❑ Certified copy is hereby furnished.' - -
Z Z '❑ Certified Copy is.filed with the,cily inspection ci3bion. FIRE 6PRINK ENERGY T-24
FO Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y.❑ 'N❑ '.
w - PERMIT ISSUANCE - 6.00
LU - CF:RTI PIC ATE E SATI MINS FROM WORKERS' FLDOD ZONE - � .A.L.U.C.
1 Q - COMPENSATION INSURANCE PLG.CONTE. LIC.N0. TOTAL .Y❑ N❑, •Y[:1 NEI,
(This ldad action need not be completed if the permit is for one
D Z hundred dollars($100)or less.) '-
U O 1 certify that in the performance of the work for which this per-- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL,F ` mit is issued,I shall not employ any person in any manner so as to
U., become subject to the Workers'Compensation Laws of California. -
�'a. - Date' Applicant ALTER OR ADD TO MECH. 4.00 BUILDING . ..3P2
of
} N NOTICE TO APPLICANT: If,after making this Certificate Ex- - .
F Z emption,'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.M.) 3.00 -
`-'CONSTRUCTION LENDING AGENCY ' AIR HANDLING UNIT(OVER I0,000GF.M.) 5.00 SEISMIC FEE Qr
1 hereby affirm that there Isla construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work,for'which this permit is issued(Sec. - MICROFILM
3097,CDC.), � 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 -
Icertify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information,is correcC I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or.100,000 B.T.U) 4.00
hereby authorize representatives.of this city to enter upon the BOILER-COMP (Ovei100,000 BTU)SEE FEE SCH. MECHANICAL
.above-mentioned property for inspection purposes -
(We) agree to sava,'indemoify and keep harmless the City of - MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costsuidl expenses which - PERMIT ISSUANCE - 3.00 . CONST.TAX
may in any way accrue against said City in consequence-of/he
granting of his permit" MECH.CONT. LIG N0. MECH. q
,v1 TOTAL TOTAL /
Nt Signature Icanl/Conlrec for D e .
I •
. - :.OFFICE COPY