5636 APPLICANT TO FILL IN INFOR TION WITHIN RED LINES - USE BAJJPOINT PEN ONLY
. Bli1LDING PROJECT IDENTI FICAT TION & PER PERMIT NUMBER
APPLICATION
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TDrRLS O
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5636
Cftsll,RS PLAN CHECK VALIDATION
NAME
• n�.yg ./�7�� OTV• ELECTRIC PERMIT FEE
h V HONE
ContnacTORs I UTLETS-SWITCHES-RECEP 5.00/1.00
-� LIGHTING FIXTURES 5.00/1.00
Apar r0 PPLIANCES-RESIDENTIAL 4.00
9b�7? 1PANELS 5.00 DATE OF APPLICATION
OBncNI C LIC.NO. SIGNS 6.00 PLAN CHECK FEE .C.NO.
ENc EFR Q 6fy SIGNS TRANS. 3.00
�
ARC"ON ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
arDREI's � r
4 as=.. .,,I SERVICE CHANGE 10.00 /y
o¢ z //!❑�
FOO LICENSIiU CONI'RACf( )ECLARATION
m ca
a v v I hereby affirm thI n licenser under provisions of Chapter 1 ISSUANCE DATE
y w Icommerlcing with Section 7000)of Division 3 of the Business and BLDG ELECT. PLG. NIECE.m Professions Cr r•ynit Jy yl�c in full for//{}}}•t3nppp of v
i i Lice Cla =•1D �Y / Numbs � -
9 r w Date/A_ C,nntrvctor
a Y s J BUILDING PERMIT,
¢ re4 OWNER-BUILDER DECLARATION
¢ d D INFORMATION
wI I hereby affirm that I am exempt from the Contractor's Limnsc MISC.- - REFER TO ORD
ar u o g Law for the following reason.(Sec.7031.5,Bunricssand Professtuns PERMIT ISSUANCE 6 VALUATION S/FT.
Code:Any city or county which requiresa permit to construct,alter,
¢ a G 0 improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC.
wo u requires the applicant far each permit to file a signed statement that TOTAL- PERMITTO
m he is licensed pursuant to the provisions of the Contractor's Liccnso
i i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe P�B�
4 Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
Eio
¢ I- the basis for the alleged a exemption.Any 'applica of Section en LS STORIES TYPE CONSTR.
n by any applicant fora hundred
Subjects($500plicuntmucivil penalty
of not more than five hundred dollars lSStX1).): ALTER-DRAIN&VENT-WATER (EA.) 4.00 '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: 'f he Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 5p.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that suchimProve-
memsarenotintendedor,,ffcrcd for sale.If,however,the Im ing GAS-EA.SYSTEM-11NC.40UTLET$ 4.00
or improvement is sold within one year of completion,the owner. GAS EASYSTEM OVER 4 (EA) 1,00 BUILDING USE
builder will have the burden of proving that h - . - .
e did not build or im- RES MD CON PB Oma
Prove forof sale.). INDUSTRIAL WASTE INTER. 20.00 El ❑ 0 E) 1:1❑ 1,ass owner owner.1 the Prmcontracting
operly,aexclusively with
licenwd contract.,, to con.aruct the project(Sec. 7044,Nosiness' LAWN SPRINKLERS- 1 INC 5 V.B.
and Professions Code:The Contractor s Leca.Law does not apply S.DD ASSESSORS PARCEL NO.
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 cont actors)licensed pursuant to
the Comractnr:License Law. SEWER-SANITARY- EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ Icon exenpstundcr Scc. ,B.&P.C.toy this WATER HEA:FE
RW 4.00
reason
Owner - Date WgTER SYSTE 4.00 ACC.DATE ACC.FILE NO.
WORK YRS'COMIIENSAT ION DECLARATION WATER TREATING EO 4:00
1 hereby affirm that I have a certificme Of consent to self-inmmC, ZONING ENG.SITE NO.
--J or a certificate of Workers'b C I urvnq,grta cerµfic
/I copy there. to cc.of Work m'Com'
Policy No. C.mpm;
U ❑ Cenifwd ' py;s bereb furnished.
Z Z ❑ Cenif��pP� Ilio city inspection divisio - FIRE SPRINK ENERGYT i4
_ Apphc,nt ✓y MISC.- REFER TO ORD. YE] NE] Y [D N�
W CERTI FICAI'Ii OF EXEMPTION FROM WORKERS' PERMI SU NCE 6.00 FLOOD ZONE A.LU.C.
W > COMPIiNSAT10N INSURANCE: G.CONTH. IC. PLG, ❑
CL Z (This section need not be completed
if the permit is for one ❑- �•7�7u' TOTAL Y N❑ v N❑
hundred dollars(S I00)or Tess.)
U O 1 certify that in ate performance of the work for which this per. CITY ME HANICAL PERMIT FEE FEE SUMMARY
W I- mit is issued,I shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of Califomia.
CL Date Applicant ALTER OR ADD TO MECH. .4,00 BUILDING
} m NOTICE '1'0 APPLICANT: If,eHer making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compcnvtion APPLIANCE 4.00 PLAN CHECK _
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M,) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000CRIA) 5.00 SEISMIC FEE
I hereby uffirn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issu cd(Sec. MICROFILM
3097.Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender',Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
• Lenders Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is cored. I agree to comply with all city and county - PLUMBING
ordinances and state laws relating to looking cositn¢tion, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this Ary to enter upon the BOILER-COMP 10,m100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Ifo E4bs,judgments,.costs and expenses which CONST.TAX
may in any way ADA against said City in consequence of the .PERMIT ISSUANCE 3.00
granti of OH MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of ppliwm/Contractor Date
OFFICE COPY