5869 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDIN9 PROJECT IDENTIFICATION PERMIT NUMBER
aoILpING - APPLICATION & PERMIT r
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL - `J
869
CaIMEWS - - - - PLAN CHECK VALIDATION
NAME' Q TV.
-ELECTRIC PERMIT FEE
III , PHONE
H.E ^crony UTLETS-SWITCHES-RECEP 5.00/1.00
&All 11 Lc.No. 9 /T LIGHTING FIXTURES 5.00/1.00
1aNTR.C1O.n1 APPLIANCES'-RESIDENTIAL 4.00
,D. & P„ONE �1- /o/03-PANELS 5.00 DATE OF APPLICATION
OR
SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.Na. SIGNS TRANS. 3.00
ARCH Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIN ITEMP.METER OR POLE INS. 15.00 �-
APPLICANTS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
wxz
Foo - LIf11iN$IiD CONTRACTORS UHCIARAI'ION
a u I hereby affiom that I am licensed under provisions of Chaplet 9 °,Ii' v- ISSUAN
w G m cmnmencing with Section]000)of Division 3 of the Business and - .�_ __ _ ELECT. LG. MECH.
F w Professions Code,pndply�icense fs in full fol�p an fccl,� -
z 0 m . Li cns�Cla _SJ-_JJ Lie Number 4TY � 0
q z H w UatcJ�I-d(r_Contractor(�NLoN
Y f �F=Y f�jj SlG
¢ ¢ ¢ OWNER-BUILDER UECLARA'1ION Zl� BUILDING PERMIT
a o a u INFORMATION
X
;LL F I hereby affirm that I am exempt from the Cmaracm,%License MISC.- R FER TO ORD
F u o"d Law for the following erason,(Sec.7031.5,Businessand ProfusionsPERMIT ISSUANCE 6 L..-///V)ALUATION S/FT.
Code:Any city or county which mquirma permit tomnslmct,alter' ELEC.CONTR. LIC.NO. 9, ^-
re
a> improve,demuluh,or repair any structure,prior to its issuance,also ELEC. E
0 u requires the applicant for such Permit to Gk sUmen
a signed tct that TOTAL PERMIT TO
A w m A he is licensed pursuan
to the provisions of the Contractors License - T ,
I- z > Law lChapter 9(crmmenciagwilh Section 7000)of Division 3 ofthe 71g-SPO 7-
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ IT- $ the hesis Fur the alleged exemption.Any violation ofSectiun 7031.5 STORIES TYPE CONSTR.
a � by any applicant for apernit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not Inure than Five hundred dollars(55001.1:
O I,os owner of the properly,or my employees with wages as BACKFLOW PROTECT.DEVICE. 2.00 Dec.GROUP .UNITS
mk compensation,will do the work,and the structure Is not
intendedor offered for tele(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 thereon,and who does such work FIXTURES-PER TRAP 4.00 r.FL R AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
oteats am not intended or offered for sate.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement n sold within one year of completion,the owner- GAS EA.SYSTEM OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that h - -
e did not build or ins- -
proveforpurpose ofsale.) - I NDUSTR IAL WASTE INTER. 2000 RE IND CDN PS Other
❑ I,ns owner of the property,am exdusivcly contracting with .
licensed contractors to construct the protect(Sec 7044,Business LAWN SPRINKLERS 1 INC 6'V.g: 5.00 ASSESSORS PARCEL NO.
and Professions Code:l'be Contractor's License law dose not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts lot such projects with a contractor(s)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam cxemnl under Soc. ,B.&RC.for(his WATER HEATER W/VENT
reason 4.00
Owner Dore WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 4.00
1 hereby affirm that I have a cenificate of consent teself-insure.
UZONING_ ENG.SITE NO.
or a niGcate of Workers'Compenmlion Insurance,or a cenifed
copy thereof(Sec.3800,Lab C.).
Policy Na. Company _
❑ceCertilled copy is hereby furnished. '
Z Z ❑ Certified copy is fled with the city inspection division. FIRE SPRINK ENERGY T 34
MISC.- REFER TO ORD.
O Applicantv F] ryy NE]
CC
CERTWICAI1 OI:1 X MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCIiPLG.CONTR. LIC.N0. PLG.
(This xenon need not be completed if the permit is for one TOTAL V N� V Nr
hundred dollars(SIM)or Icscl
U O I certify that in the Performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner m as to
U bemm m 'est o he Workers'Open tion laws f Cali(omi
U y Dam- Appluanl L,72! "" �/ -we '� ALTER OR ADD TO MECH. 4,00 BUILDING
} m N'O'I'I CE 'f0 APPLICANT': 1f,a0cr making this Certir e of F.-
sorption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Codes, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 1Q000CF.MJ 3.00
CONS'I'RUCI'ION LIiNUING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE Sy
I hereby affirm that them is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2-DO
the performance of the work for which this permit is issued(Sec MICROFILM
3077,Civ.CJ. HEATING UNIT(TO 100,000 B.T:U.) 4.00
Lender's Name HEATING UNIT(OVER 100.000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this upplicutmn and state that the above VENTILATION FAN (SINGLE) 3.00
information is coned. I agree to comply with all city and county PLUMBING
P ordinances and slate laws relating to building construction, and BOILER-ODAP(3 H.P.or 100,000 B.T.U.) 4.00
hereby above-mentioned
representatives ec the city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby entioned 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 300 CONST.TAX
may in any way accrue against said City in consequence of the
gran. gofth I MECH.CONT. LIC.NO. MECH.
da �i _ - TOTAL TOTAL Oa
Signature of Applicant/Cont 5PRY, Uele -
OFFICE COPY _