5867 1
APPLICANT TO FILL IN INFO TION WITHIN RED LINES - USE B POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICA PERMIT.NUMBER
BUIL NG APPLICATION & PERMIT
nH! / n
y �r 0 N)G� 6V� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
5867
ream",'s - - PLAN CHECK VALIDATION
OTV• ELECTRIC PERMIT FEE
CONTRACTOR 5
UTLETS-SWITCHES-RECEP 5.00/1.00
(�J•v!) C.� Lia.uo�l7�./l-+L HTI
LIGNG FIXTURES 5.00/1,00
rouTEAcrons - PPLIANCES-RESIDENTIAL 4.00 f
I �7
pyLl�/LF UfIt"PNONEp[ PANELS 5.00 DATE OF APPLICATION
ORRCw ECT SIGNS 6 PLAN_CHECK FEE .NO.
.ENGINEER
Lie.rvo.' SIGNS TRANS. 3.00
ADDRESS Enc. SPECIAL CIRCUIT 5.00 _ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
A.EFESS oREsS
SERVICE CHANGE 10.00
o a o LICENSED CONTRACTORS DECLARATION
a ZI hereby ufNm rthat I am licensed under provisions of Chapter 0 ISSUANCE DATE
a. (commencing with Section 7000)of Division 3 of the Business and
D z Professions Calpprlllpy Ikense is in full fort, rut 5,1. Z ELE❑CT. PL❑G. MEG .
Licenv;Cl 4 •CV Lic.Number „ya`_'f�
9 F o
rode-19 Contractor_/�. -
8 l-'
M OWNER-BUILDER DECLARATION BUILDING PERMIT
u, u INFORMATION
w , r I hereby cert into that I am exempt from the Contractor's License MISC.- REFER TO ORD
r LL o a Law for the following reason.(Sec.7031.5,Busincssand Pmfccsium PERMIT ISSUANCE 6.00
VAw ATION
Cale:Any city or county which requiresa permit toconstruct.alter,
a ¢ 0 improve,demolish,or repair any structure,prior to its issuance,dw ELEC.CONTR. LIC.NO. ELEC.
C u requires the upplicanl for such pennit to file a mgned statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
r a i Law(Chapter 9(commencing with Suction 7000)of Division 3 oflhe
4 Business and Professions Code)or that be is exempt therefrom and OTY. PLUMBING PERMIT FEE IV
EE F-$ the basis for the alleged escmption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by tory applicant for a permit subjects the applicant to a civil lwnally ALTER-DRAIN -WATER (EA.)of not mom than five hundred dollars(S500).): -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2-DO OCC.GROUP RES.UNITS
their sole compenmtion,will do the work,and the stn,,W,is not
intended or offered for sale(Sec. 7044. Business,and Professions DRAINS-FLOOR,ROOF,AREA,COND- 4.DO
Code:The Contractor's License law does not apply to an owner of
Property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employes,provided that such improve-
mentsarcnot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
ser improvement is 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 he did not build or NI-
provefor purpose ufsdc.). INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Orem
O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'f lit Contractor's License Law dews not apply
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 ontract.r(O licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.RP.C.for this WATER HEATER W/VENT 4,00
reason
Owner Datc WATER SYSTEM 4.00 ACG DATE ACC.FILE NO.
WOkKI7RS'COMPIiNSATI0N DECLARATION WATER TREATING EQUIP. 4.00
I hereby al firm that I have a certificate of consent to self-insure,eZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or u certified
copy therecl(Sec.3800,LOC.).
Policy No._ Com y
O Ccrtific p h y(urnl FIRE SPRINK ENERGY T-24
z { s�Certi o pYs ti d w' t city ins(�ection division.
O Applicant a/�` MISC.- REFER TO ORD. Y ❑ N❑ YE] NE]
0CN PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
CIiRT119CATE OP Iixl`%WTIO.' -ROA(WORKERS'
LU 7 COMPENSATION IN RANCE PLG.CONTE. LIC.NO. PLG. V N Y N�
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars($100)or Icss)
U O 1 certify mat in the performance of me work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
UL H out is Hsucd.I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California.
OL Dare Applicant BUILDING
} w NOTICE TO APPLICANT: IL after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
? cmptioo,you should become subject m the Workers'Coll pen,atim, 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 ITO 10=C.F.Nk) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C-F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction Icnding agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
San,Civ.C.). HEATING UNIT(TO 100,000 B.T.0-) 4.D0
Lender's Name H EATING UNIT(OVER 100,000 B.T.U,17.50
Lender's Address ELECTRIC
I certify that l have read thisappliemium and state that the above VENTILATION FAN (SINGLE) _3.00 -
• information a correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CObP(3 H.P.or 100,000 B.T.U.) 4.00
\ hereby authorize representatives of this city to enter upon the BOILER-COMP (Over1170,000 BTU(SEE FEE SCH. MECHANICAL
1 above-mentioned prope y for inspection purposes.
(We) agree IU save, indemnify and keep hanalsv the City of MISC.- - REFER TO ORD.
Cupertino ainst li;�ilities,judgmems, costs and ex ses which PERMIT ISSUANCE 3.00 / CONST.TAX
may in ay true ug ' said City in conseq nee o the
gmntit 1 of i p nit' � MECH.CONT. LIC.NO. MECH.
TO / TOTAL 2
arum of Applicant/Contr or Date - G.
OFFICE COPY