5491 40LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- r BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5491 A n
ADDRESS "�L�`J I
f AUTl.�Q BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME ' DTV. - .,ELECaTRIC,FERMIT FEE
.:;.-
VRON d.,
.AMERAc7oR's UTLETS-SWITCHES-RECEP 5.00/100 sem.
I.M.ND.
LIGHTING FIXTURES 5.00/1.00 I '
C-DNTRACroms PPLIANCES-RESIDENTIAL 4.00 '
A DRESS
PANELS 5.00 DATE OF APPLICATION
A CHIT CT SIGNS 600 PLAN CHECK FEE P.C.NO.
OR _
ENGINEE
uc. SIGNS TRANS. 3.00
ADDRiSSS ENG. SPECIAL CIRCUIT 5.00 PERMR_VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
A DRESS MOTORS SEE FEE SCH. �
'
ADDRESS
s✓ CZ- SERVICE CHANGE 10.00
aA/d f°
D O o LICENSED CONTRACTORS DECLARATION
u v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
m Z w' (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
F N i Prul'esslo Cale,and my license isN full fore d ffie '� A
i D m late I.ic.Number .(( -(p- �c
O T-O Date Coolmdor
tw
a Y s
a o:w u NIiR-BUILDER DECLARATION ;4..
YF I , ATION
x;LL I- I hereby at that l am exempt from the Con tremor s License MISC.- I VALU I
..„A Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE - 6.00
Code:Any city or county which requires a permit construe(, 3 �0'fl
eac a O improve,demolish,or repair any structure,prior to ifs issuance,also ELEC.CONTR. LIC.NO. ELEC. /
-O LL requires the applicant for such permit to file a signed statement End TOTAL M
wm he is licensed pursuant to the provisions of the Comractor's License
e. i Law(Chapter 9(commencing with Section 7000)of Division 3 of the �.w P` i d b oP 'y !QE/`J�GE6 �'U7f3Q/0
a Business and Professions Code)or that he is exempt therefrom and QTY.d a seroPLUMBING(RERMITpy .yi ?`4'y. . FEE
Ic H D Inch I'or the alleged exemption.Any violation of Section 7031 5 -• - rte.', ' I s "°- _ sTt STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally
of not more than five hundred dollars(E5oo).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the properly,'or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.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
property who builds or improves(hereon,and who does such work FIXTURES-PER TRAP 4.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4OUTLETS 4.00
or'ililprovemem is cold within one year of completion,(he owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Diner
/J prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20100
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ - ❑
licensed contractors ID 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 contnetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. =PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00 '
reason
Owner Date WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Campeemlion Imomnee,or a certified
copy Ihemol'(Sec.3800,Lab.C.).
Policy No. Company
Q ❑ Ccnifie opy is I emby famished. FIRE SPRINK ENERGY T$4
Z Z ❑ Cerl' y he city inspection division. MISC.- REFER TO ORD.
Q Applic: Y [-] N❑ Y C] N[]
W CERTI EOE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00FLOOD.ZONE A.L.u.C.
PLU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. I.G.
CL 0 (This section need not be completed if the permit is for one TOTAL` Y❑ N❑ Y [-] NE]
0 Z hundred dollars IS 100)or less.) -
U 0 I certify that in the performance of the work for which this per- QTY.su , MECHANICAL"PERMIT 'FEE FEE SUMMARY
LL P mil is ised',I shall not employ any person in any manner so as to -
O W become subjec[.to the Workers'Compensation Laws of California. _ BUILDING //�If
Date Applicant ALTER OR ADD TO MECH. 4.00 �.,
} y
NOTICE; TO APPLICANT: If,after making this Certificate of Ex- .
H ? emption,you should.become subject to the Workers'Compensation APPLIANCE PAILJ4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 3.0
CONSTRUCTION LENDING AGENCY AIR HANDLING (OVEWflOE3 F- .) SEISMIC FEE
1 hereby affinn 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. HEATING UNIT(TO 100, f,Ip MICROFILM
30odr,'s97. .0 r-e4y M it ft
Lender's Nam -
Lender's Address 'HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC"
1 certify that 1 have read this application and slatethat the above VENTILATION FAN (SINGLE) 3.00 3 ` - I,
information is correct.1 agree to comply with all city and county t PLUMBING
ordinances and slate 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 (Over 100,000STU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against I'abilities,judgments, costs and expenses which 1 CONST.TAX
may in any way ecrue against said City in consequence of the PERMIT ISSUANCE 3.00 =
g gof this mi(. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
na care of pph nt( ontrac(o Date y
OFFICECOPY - - .