18874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING ,APPLICATION & PERMIT 1887 o I�
ADDRESS t.1 o I
�L (\� BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNERS "+ PLAN CHECK VALIDATION
NAME �y� OTY. ELECTRIC PERMIT FEE
FHDNEa�rl
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00'
LIC,No,o LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
AoDRESSPPLIANCES-RESIDENTIAL 4.00
DRESS 11 Z
PHDN ��J� PANELS 10.00
DATE OF APPLICATION
ARCHITECT (OVER 200 AMP) 20.00 PLAN CHECK FEE P.0_NO.
R
ENGINEER
- tic.NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 G D
ADDRDDRESSSS
AEMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o ¢z (l
r
OL
LICENSED CUN'I'RAC'I'(lBS DECLARATION
a Z w 1 hereby afl'inm n that 1 nlicensed under provisions of Chuptcr 9 ISSUANCE DATE
N< N (commencing with Section 7000)of Division 3 of the Business and O BLDG. ELECT. G. MECH.
F m z Professions Code,and my license is in full force and effect. T I (�y 1�yJ ❑ ❑ El
o os License Class Lie Number
o - hale Contractor
a , s city of f:UOP. � BUILDING PERMIT
g a w p owN1:R-BuaUF;R DECLARA'UON INFORMATION
w ; I r I hereby affirm that 1 an exempt from the Contractor's License MISC.- REFER TO ORD
LLoa Low in,thefollowing r,u,00.(Sce.7031.5.Businessund Professions PERMIT ISSUANCE 10.00 VALUATION 3/FT.
- Code:Any city orcounty which rcquiresa peril loconstruct,ultcq
Q2 ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e w es w he is licensed pursuant to the provisions of the Contractor's License
rz> Law(Chapter 9(commencing with Section 7000)of-Division 3 ofthe
m o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r p the basis for the alleged exanhptiou.Any violation it Section 7031.5 41 DRIES TYPE CONBTR.
c ; m by any applicant for a perout subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not marc than five hundred dollars(S500).):
❑ I,as owner Of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP - RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or olfurcd For sole (Sc,. 70449 Business:std Professl0m DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
Cod,:The Cimrmcloh Liccnsc Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sO.FT FLooR AREA TOTAL ACREAGE
.,chimself through his own Rcied fors provide)that such improve-
or imprre nocni is s ed or within on year o lL lin lesion(he the o ncr- GAS-EA.SV STEM-1 1NC.40UTLET$ 6.00
or lder will h have
is sold within one you id Conhpld ion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will purpose
the burden o(proving that he did nal build or inn- BUILDING USE
prove fors owner of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ower
❑ L as owner of the property,am exclusively ec (See.
contracting with Q ❑ ❑ ❑ ❑
licensed contractors ors Code: I construct the project IScc. does of apply LAWN SPRINKLER$- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions propproperly
who
License s O docs not apply - ,
to tr owner of h projects
builds or improves tnsed pursuant
sena who LAWN SPR INKLERS-OVER 5(EA.) 1.00
contracts ct such projects with a contractor(s)licensed pursuant In SEWER-SANITARY-STORM EA.200ft/10.00
the [amc exempt
License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sea .B.fiP.C.for this WATER HEATER W/VENT $90
reason
Owner [)ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'1ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby attlrm that I have a certificate of conwot to selbinsum,'.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof'(.Sec 3900,Lub.C.l.
Policy No, Compmy -
O ❑ Certilied copy is hereby furnished RE SPRINK ENERGY i-N
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.O Applicant Y Q . NE] I Y E) NE]
CC CER I'IPICA'1'Ii DIs EXEMPTION FROM WORKFRS' PERMIT ISSUANCE 19:90 a.�p FLOOD ZONE A.L.U,o.
OI > COMPENSATION'INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This action need not be completed if the pennit n for one TOTAL Y❑ N� Y N[]D Z hundred dollars(S 100)or less)
00 1 certify that in the ptrk>rmnnce nl'the work for whichthis per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is(sunt J,I ha11 not employ any pcnun in any num", as to
O L) become subject to the Workers Compensation Laws of California.
d Dale Applicant BUILDING
} 0 NO]'ICE rO APPLICANT: If,after making this Certificate of tic ALTER OR ADD TO MECH. 5.00
Z empGon,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Coda you must forthwith comply with FEE
U such provisions or this permit shall be deemed rc,.k,d. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C.F.M.) 6.00 SEISMIC FEE
I h,reby, ptr that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Perbormunce of the work for which this permit is issued(Sec. MICROFILM
3097,Co,.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Noma H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply will all city and county PLUMBING
ordinances and slate laws relating to buildtng cmhstuaitm, and OIL
6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE PEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep ha,u less the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmcmis, Costs and expenses which CONST.TAX
may many way accrue against said City in cmucquence of the PERMIT ISSUANCE 10.00
ranting of this permit. MECH.CONT. LIC.NO. MECH.
Signature of Applicant/Cnnlructor DWTOTAL TOTAL ) q , Czi
OFFICE COPY