6182 IAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/ BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^ A ^
ADDRESS b I G
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S JJ PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT . .FEE
n orvE
NONrRAcroRs
OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
,�7-�-� LION 'p LIGHTING FIXTURES 5.00/1.00 Of
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00 ( ^
A �x
7 1y HONE �K PANELS 5.00iqL-::: DATE OF APPLICATION
ARCHITECT SIGNS 6A0 PLAN CHECK FEE I P.C.NO,
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARCH.DR ENG. SPECIALCIRCUIT SAID PERMIT VALIDATION
ADDRESS
ZIP FrEMP.METER OR POLE INS. 15.00
APPLICANT', MOTORS SEE FEE SCH.
AOORr.
SERVICE CHANGE 10.00
w o a LICENSIi1)CONTRACTORS DECIARATION
<U 1 hereby affirm(hal I am licensed under provisions of Chapter 9 ISSUANCE DATE
H rt wa (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H z Professions Code,���yyyllyd.myyy license is in full fo o-2 t.�,� ❑ r-vl ❑ ❑
z o u, - License ClaF-( Lic,Number �'/-�,5 - Ju
DzHw DaCoNr nor
a x s `.BUILDING+PERMIT
re cw OWNER-BUILDER DECLARATION "INFO RNIASTII ON
w0
a I hereby affirm that I am cxempl from the ContractorVALUATION SIFT.
's License MISC.- REFER TO ORD -
.LD¢w Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE
� - Code:Any city tolerantly which re9uiresa permit tocollslruct,alter, 8.00
tea ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO: ELEC
TOTAL.
O¢ requires the applicant for such permit to Isle a signed statement that PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
H z a
Law(Chaplet 9(commencing with Section 7000)of Division 3 ofthe ELEG7
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
K f the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant mbjeca the applicant macivilpenalt
m y ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500)):
❑ 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 (Sec. 7044. Business and Profession DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: The Contructur's License Law does not apply to an owner o1'
property who huilds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve
menti are not intended Or offered for sale.If,however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 4.00
orimprovement is said 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 to int.
prove l' se or propose ofsale). INDUSTRIAL WASTE INTER. 20.00 0 El El ❑ ❑
RESIND cos PB Other
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
amends me-,',License
with a wmrunor(s)licensed pursuant m SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Cads f turas h projects
taw.
❑ I am exonpl under Sec.-,B.&P.C.for this WATER HEATERW/VENT, 4.00
reason
owner Date WATER SYSTEM - 4.00 ACC,DATE ACG FILE NO.
WORKhRS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby atlirm that I have a certificate•of Consent to self-insole. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See 3800,Lab C.).
Policy .. COm Pany. L�MA'�� LN3" i
O W lerlilkd copy'is hereby l Mrohed. FIRE SPRINK ENERGY T 24 ^
Z2 O Certified - py s 'ed with the m) inspection division. MISC.- REFER TO ORD. Y N❑ Y ❑ N(D
O Applican(_
ir CIiR'I'IFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOO ZONE A.L.u.c.
W
LU > C0MI4ENSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O ('Phis section need not he completed if the permit is for one TOTAL v❑ N❑ Y ❑ NEI
2 hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Q w bccomcyubjea to the Workers'Componsution Laws III California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
>- so NOTICE TO APPLICANT : If,after making this Certificate of Ex.
? eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mus( forthwith comply with FEE
U such provisions or this permit shall be,deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that Deere is a emistruclion lending agency fur EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sea HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C).
I-ender',Nome'
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC Q '-
I ceNlfy 01.(Ih.sc,cad thlsappbcxHom and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree m 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 aUth..rice representatives of this city to enter upon the BOILER-COMP.(Over 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue agains aid City in c.eveti ,ree of the
grunting Uf 'Pcr il.' MECH.CONT. LIC.NO. MECH.
lD TOTAL TOTAL
gnutarc o A Vl hc.MICon,actor Date
OFFICE COPY
I