6565 PPLICANT TO FILL IN INFORMATION WITHIN REDLINES- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
APP PERMIT
amLotNG _ LIGATION & _ 6565 c
AOO�REss ` i.1
ILV\ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
L
PLAN CHECK VALIDATION
NAME CITY.. ELECTRIC PERMIT" - FEE
• AmAralogmy, PMONS9
cAMERACU.S UTLETS-SWITCHES-RECEP 5.00/1.00
LIE.No LIGHTING FIXTURES .5.00/1.00
CONTRACTOR'S APPLIANCES-'RESIDENTIAL - 4.00
oR ss r�,,l�E�
e, 1Y���Q vNo� qCA0
..PANELS -5.00 DATE OF APPLICATION
OnciRlmlT ' SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDDRESS ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 r
Ar$
ADDRESS
ESS MOTORS. SEE FEE SCW J
ss
SERVICE CHANGE 10.00 //h�
w O o LICENSED CONTRACTORS DECLARATION In /N
a U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r z w (commencing with Section 7000)of Division 3 of the Business'and,4¢ vAim
BLDG. ELECT. PLG. MECH.
0 y Z Professions
D. my license is in full force and effect ❑ ❑ Elz ,n- License Class_ Lie.Number
Canino.,_
a m f =I BUILDING PERMITS
OWNER-BUILDER DECLARATION
m au sa - INFORMATION
`Xn ;LL y I heeby affirm that I.a r exempt from the Contractor's License MISC.- REFER TO ORD
Ru0j Law for the following reason.(Sec.7071.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city or county which requires permit to construct,alter,
a,¢ < FO improve,demolish,or repair any structure,prior to its issuance,also ELFC.CONTE. LIC.NO. ELEC. _
a wo LL. requires the applicant for such permit to file a signed statement(hat TOTAL PERMIT TO /
'm he is licensed pursuant to the provisions of the Contractor's License �ON
H z s- Law(Chapter 9(commencing with Section 7000)of Division 3 of the " 24G/EJ04,'�
4 a Business and Professions Code)or that he is exempt therefrom and OTV. - - PLUMBING PERMIT -FEE
the basis for the alleged exemption.Any violation of Section 7031.5 . TBHIFr �„TV`V j'
; - by any applicant for a permit subjects the applicant loacivilpenalty ALTER-DRAIN (EA.14.00
of not more than five hundred dollars(5500).): QN�
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 - OCC.GROUP RES.LOTS
(heir 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
sf$ ��•\\ property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
y or improvement is sold within one year of completion,the owner-
-ti builder will have the burden of proving that he did not build or im- IGAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
Pt prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CDN PB ower
❑ I,as owner of the properly,am exclusively contracting with 20.00 0 ❑ C1 ❑. 11
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-11 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 contraclons)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. - PARCEL NO,
❑ lam exempt under Sec.-,BAP.C.her this WATER HEATER W/VENT 4.00
reason '
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
•WORKERS'COMPENSATION LECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of Consent to self-insure, -
ora certificate of Workers'Compensation Insurance,or a certified ZONING ENG SITE NO.
copy thereof(Sec,3800,Lab C.).
P tic No.-Company_>j�-i
-
Q CN,
ted copy is hereby fumisbed. FIRE SPRINK ENERGY T-24
Z Z ❑ CeRili If co Filed wit the 'i ins c ion division. MISC.- REFER TO ORD.
Applicant P: V N 0 V N
Cr - CERTTI PICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL V N❑. V O No
D Z hundred doll...(8100)or less.)
L) O -1 certify that in the performance of the work for which this per- UTV.. x. MECHANICAL PERMIT -FEE FEE SUMMARYy
H Intl Is Issued I shall not employ any person In any manner so as m 'n+ '
U become subject to the Workeri Compensation Laws of California.
y Dale can
1 ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of (he Labor Code, you nest forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMCF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10AMC.F.M.) 5.00 SEISMIC FEE (Q �
1 hereby affirm that there is a cr9istruction 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 HEATING UNIT(OVER 100,000 B.T.U.17.50
61 -
Lender's Address ELECTRIC
E I certify that I 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 cotmty PLUMBING
ordinances and state laws relating to,building construction, and BOILER•COMP(3 H.P.Or 100,000 B.T.U.) 4.00
1 hereby authorize representatives of this city to'enler Inion the
r., ,ie. ab.vc.mm�ti.md property for inspection purposes. BOILER-COMP(Over 100,000 BTUI BEE FEE SCH. MECHANICAL
4 (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino Ing 'cost liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any ay accrue against said City in consequence of the
ng of tlo could. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignaureo pplicanl/Contract Ualc
OFFICE COPY
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