1872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 3X
BU I LDING PROJECT I DENTIFICATION a PERMIT
RU ED INC, ,APPLICATION & PERMIT
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AooREss , / r 0 11"✓IG J// BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
72
OwNER'S PLAN CHECK VALIDATION
NAME D/U E. .1 9A 3CITY ELECTRIC PERMIT FEE
C
HONE t
CONTRACTOR'S
NAME 'Y' OUTLETS-SWITCHES-RECEP 5.00/1.00
H 3rNG LIC No. C�4/7Z LIGHTING FIXTURES 5.00/1.00
7
REss ACTOR S'
APPLIANCES-RESIDENTIAL 4.00
D
A O� }�1, T PHONE), /7
ZZ. PANELS 5.00 GATE OF APPLICATION
ORCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No. SIGNS TRANS. 3.00 r
ADDRESS ENG
SPECIAL CIRCUIT 5.00 PERMIT���.VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
ADr$
ADDRESS MOTORS SEE FEE SCH.
RESS Ess
SERVICE CHA GE 10.00
GSE i
i
02 LICENSED CONTRACTORS DECLIRAT'ION rJ
a v w 1 hereby affirm that I am licensed under provisions of Chapter 9 -ISSUANCE DATE
n (commencing with Section 7000)of Division 3 of the Business and
¢w SLOG. ELECT. PLG. MECH.
R y z Pro(essons CodC, d enac is in full for c u d r�
a O m Liccnscg -��'C-Ric.Number /��(Z�-.y- � � � � Z f
y ti Date (4- 7 r7�Contrudor %(-/_ca-
¢ Y F J 'a �' �� BUILDING PERMIT
¢ ¢ OWNER-BUILDFR DECL\RA'I']ON
o se 0 INFORMATION
w ; m 1 hereby affirm that I am exempt from the Contractor\License MISC.-' �� W1 'REFER TO ORD
Fu 004 Law for the following mason.(Sec.7031.5.Business and ProfessionspERMI7185UANCE 6.00 VALUATION S/FT.
Code Any city or county which requires a permit to construct,alter,
¢ 0 improve,demolish,or repair structure,prior its issuance,also ELEC.COINER. LIC.NO. ELEC.
- D lC requires the applicant for such permit To We a signed stutcnnnt that TOTAL PERMIT TO f
A
is m y he is licensed pursuant to the provisions of the Contractor's License _s
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
m o Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE
to > C, the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five Readied dollars 15500).1:
❑ 1,as owner of tireproperly,or my untployccs with wa,cs'us BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole cons peosatlon;will do the work,and the structure',not ,
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code-'fire Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.005D.FT.FLOOR AREA TOT
men"
himself or through his own employees,provided that such improve-
menu arc not intended or offered for sale.If,however,lire building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 _
I Or improvenmet is sold within one year of corel letion,the owner-
. builder will have the burden of proving that lie(lid not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose ofsale.)' INDUSTRIAL WASTE INTER. RES IND CON PB Gibe,
❑ 1,as owner of the property,an exclusively contracting 20.00 ❑ 0 ❑ 0 ❑
p tr t e g with and
pre contractors o Cole:m construct the project La 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B.
S.00 ASSESSORS PARCEL NO.
trod Professions perry Conuo improv s th Joos non apply
to tr owner of property who ra builds. or improves Thereon,and who LAWN SPRINKLERS-OVER 51EA.1 1.00
contracts fnr ct.,'s e...ctswitlt uconinmorlsl licaucd pursuantm SEWER-SANITARY-STORM EA.200ft/8.00
the Cunlmcto�s Liccnsc Lw. TRACT NO, PARCEL NO.
❑ I as exempt ender Seo. .B.&PC.tin this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE• ACC.FILE N0.
W'ORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a e tificam of consent to self-insure. '
or a certificate o'Workers'Contpervaron Insurance,or u certified ZONING ENG.SITE NO.
copy thery���}$ggpp��}}}{17p[1YY-al,C.I
POIicY Nr1S_4 LICnmpany E711/TLt f
0 ❑ Certified copy is hereby furnished. -
Z Z "Ti"uf copy.�[[h�eppcity,,l��S1P�ec wt IOn. FIRE SPRINK' ENERGYT 14
F 0 Apprcnm_12 =,CH1 L'LrcF/-� MISC.- REFER TO ORD. Y[] NE] Y ❑ NF
CC w CFRI 117ICATE OF I'M MIN[ON PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U,C.
Lid COMPIiNSAI ION INSURANCE PLG.CONTE. LIC.NO. TOTAL v E] N F] v EJ . N
CI his section need riot be completed if the permit is fur o
Z hundred dollars(S100)or less.)
0 O 1 certify that in the per strmvnce of to work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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.
LU OL
Date npphcca ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after nwking this CcRificate of Ex-
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
CON'STRUC'TION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the I)cRoriance of ere work for which this permit is issued(Sc, MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I eerily that 1 have read this application and state That the above VENTILATION FAN (SINGLE) 3.00
. info.....ion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws miming 10 building construction, and BOILER-ODMP(3 H.P.Or 100,000 B-7.U.) 4.00 Ll-/
hereby uuthori/e representatives of this city to enter upon the BOILER-COMP m (Over 100,000 BTU) FEE SCH. MECHANICAL' 1aiv 5�
abovrentioned 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 against said City in consequence of the
AIH
granting of it)
permit. MECH.CONT. LIG''//NO. MECH. rr �f,
�?�--' 'il �� TOTAL/ ,7 o TOTAL - I
Sgnat of App moot intra 0r Dutc ✓
OFFICE COPY