4476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATION PERMIT NUMBER
NO LEING APPLICATION & PERMIT 4476
ADDREs
w 5� IDP-- BUILDING -ELECTRICAL-PLUMBING-MECHANICA
�\ UNMER'S
B Z52 5z(,3 CITY. ELECTRIC PERMIT FEE LECK vnuonnoN
R°NE
N°ME""°T°"s UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
DR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
A
wl°NE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 5 DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
sec.NO, SIGNS TRANS. 3.00
ADD Ess ENc. SPECIAL CIRCUIT 5,OQ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15,00 D �n
APPLICANTS MOTORS SEE FEE SCH. �]
ADDRESS p]
SERVICE CHANGE 10.00 �QR4
o ¢ i 11 ((
F O D LICENSED CONTRACTORS DECLARATION V S Z
u U I herchy'v ffinn that I um liccnscd under provisions of Chapter R ISSUANCE DATE
mR i (commencing with Section 7000)of Division 3 of the Business and
¢ MECH.
r o i Professions Coda and my license is in full force and effect D- 3 ❑ ❑ ❑
z o w License Claus Lic.Number
9 F Date Contractor
a y E1,61.0 _BUILDINGPERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
a o w u INFOR
X
g: MATION
LL _ I hereby affum that I am exempt from the Contramor'+License MISC.- REFER TO ORD
H, LLoa law for the following reason(Sec.703L5,BusincssmW Professions PERMIT ISSUANCE E1.y. Ano S/FT.
a Cale:Any city or county which requires a permit to construct alter. 6'� "���
IS
¢ ¢ hiiiilELE
o improve,demolis ,or repair any structure,prior to its issuance,also G CONTR. LIC.NO. ELEC
O LL rmi
requires the applicant for such pet to mile a sighm
ed statement that TOTAL PERMIT TO
w2 he is licensed pursuant to the provisions of the Contractor's Lievnse �s
FiQ Law(Chapter 9(commencing with Section 7000)of Division 3 of t he m �1
Itusineas and Professions Code)or that be is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ _ the basis for the a ora exemption.Any violationofSeniors 703 1.5 STORIES TYPE CONSTR.
A , by any applicant fora permit subjects tire applicant ora wacivil penalty ALTER-DRAIN -WATER (EA) 4.00 kr4X�' /N CrC-ecr
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 occ GROUP RES.UNITS
their soil,compensa ion,will do the work,and the structure Is nut
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '� NT
Code:The Contractor's License Law dun not apply m an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 Se.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offend for sale.If,however,the building GAS-EA.SYSTEM-11INC.4 OUTLETS 4.00
or improvement is,wild within one year of conlple Hon, the owncf GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 ,BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsalc.)4 INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ 1,as owner Of the Properly,and exclusively contracting with ❑ ❑ ❑ 0
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profcsnons Code The Colaructor's License Law does not apply
to an owner of property who hands or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1,00
conthe Cont for Contractor's
proierscL with 8contractors) ICCOSCd p11MIa0t t0 SEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO. PARCEL No.
the tracts or su License Law.
❑ I am exempt under See. .B.&P.C.for t is WATER HEATER W/VENT 4,00
fico on1 051
� nate � w WATER SYSTEM 4.00 Ace.DATE ACC.FILE NO.
WORK ERS'COMPENSA'TIO. .CLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm (but 1 have a certificate of consent to sell-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certifwd
copy thcrcof(Scc.3800,Lab C.). _
POlicy No. Company _
Q 0 Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z = ❑ Certified copy is riled with flus city inspection division. MISC.- REFER TO ORD.
F 0 Applicant Y ❑ NE] Y NE:]
cc N CERTI FICA TIS OIr EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO PLG. v N Y N
CL 0 (This section need not he completed if the permit is for one TOTAL
2 hundred dollars IS 100)or less
U O 1 artily that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any terrier Vo as to
O w bec fire subject to the Workers'Compensation Laws of California. 9
Q. Date ApplicantBUILDING 3If-
} 0 NOTIC17 TO APPLICANT: If,after making this Cerlifcate of Es. ALTER OR ADD TO MECH. 4.00
2
emption,you should become subject to the Workers'Compensatiun APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Coda you must forthwith comply with FEE
U such provisionsor this pertit shall he demned revoked. AIR HANDLING UNIT(TO 10000QF.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is onstructiou lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued f5ec.
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's Add n-ss ELECTRIC
I certify that I have read this application and swte that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to amply with all city and county PLUMBING
ordinances and state laws relating to Comply
buildi with9 cunstruclion. and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 4.00
hereby uuthorire represenwtives ul this city to enter uPun the BOILER-COMP (Oser 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Rv. indemnify and keep harmless (he City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE .300 CONST.TAX
ma any way accrue against ui City in consequence of the
gr tin of this permµ.,., MECH.CONT. LIC.NO. MECH.
\` L7a�/{ TOTAL TOTAL �' �0
n Sign re of Applicant/Contractor Date
OFFICE COPY