6304 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
RDDOESS APPLICATION & PERMIT O
APPREss
�+ _2_ _r — ��� BUILDING—ELECTRICAL—PLUMBING —MECHANICAL
"OWNER'S PLAN CHECK VALIDATION
�- rvAME 0 DTV• ELECTRIC PERMIT FEE
vHonE
\x' °°MER"cr°RS 6 UTLETS-SWITCHES-RECEP 5.00/1.00
0/t I;1 CI—BG 7L IC.No. Z LIGHTING FIXTURES 5.00/1.00
CONTRTORS PPLIANCES-RESIDENTIAL 4.00
A....
� 5
14 yV W TT PHONE —O / PANELS 5.00 S— DATE OF APPLICATION
ARCHITECT 1 11, LAN CHECK FEE N .
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 I
ADDRESS
ASMOTORS SEE FEE SCH Tl
SERVICE CHAPAID 10.00
o¢i
Foo LICENSED CONT'NACTORS UCCLARATION
a u 1 herebyof firm that 1 am licensed under provisions of Chapter 9 M&Y 3 Nb4 ISSUANCE DATE
m a a Nummencing with Section 7000)of Division 3 of the Business and BLDG- ELECT- I PLG. MECH.
.Professions Cad nd spy'µ se u in full for f m.
o o u.o -License Class o cis Lic.Number U 1 �'
Dam_yr i, VW___Contractor City of Pe
El
A , E � . T ���5?'4�°1- BUILDING PERMIT
w¢ OWNIi R-BUILDER DECLARA' ON INFORMATION
o u ° - MISC.— REFER TO ORD
X
I hereby ul ltrm that I am exempt from the Contractor's License VALUATION S/FT.
F LL o a Law for the following rcawn.(Sec.7031.5,Isusinessand Profusions PERMIT ISSUANCE - 6,00
Code:Any city or county which reyuiresa sensor to conswcLalter,
R ¢Qimprove,demolish,or repair any stnmturc,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
— 0 u requires the applicant for such pemmil to file a signed statement that TOTAL "�( PERMIT TO
sehe is licensed pursuant to the provisions of the Contractor's License 7
Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the
- •i Businss and Professions Code)m that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ r C` the basis for the alleged exemption.Any violation A Secti.m703I.5 STORIES TYPE CONSTR.
n ; by any applicant lot a Permit subjects the applicant lois civil Penalty ALTER-DRAIN -WATER (EA.) 400
of not more than rive hundred dollars(5500).)=
❑ ],as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sak (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License law does not apply In an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTALACREAGE
� himself or through his own emplaym,provided that such improve-
. menu are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00 ,
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND' CON PB On.,
for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the properly,am exclusively commcting with ❑ ❑ ❑ ❑ ❑
licensed umvactors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.DO ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner
rog
of peny who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoos)licensed punuant to
.the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
O lam exempt under Sec ,B.&P.C.for Chir WATER HEATER W/VENT 4-00
reason
Owner Date WATER SYSTEM 4.00 ACC:DATE ACC.FILE NO.
WORK RRS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby infirm that 1 have a certificmc or consent to sel Gimme, ZONING
or a ccrtifcatc of Workers Coslwnsdimm Insurancq or a renin ENG.SITE NO. .
cog,thertof(Set'.31100,L b.C.).ff '
Policy No. Company /f'fmo '_rate�l �alN f
O ❑ CeniFcd copy is hereby lumnhed. FIRESPRINK ENERGY T-24
z 2 A yeti d copy is filed with the sty,inspection Division. MISC.- REFER TO ORD. y N y N
cc CERTIFICAFF OP 1'.XFMP['ION PROM WORKERS' PERMIT ISSUANCE 6.00 1_Fy
oOOZONE A.cut.
W > COMPEPISATION INSURANCE PLG.CONTR. LIC.NO. PLG. E] N❑ Y F] N E]CL Z (This section Used not he completed if the Permit is for one TOTAL
hundred dollars IS 100)or loss.)
U O 1 certify that in the performance of the work for which this Per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall not employ any person in any manner w as to
become subject to the Workers Compensation Laws of California.
LU C. Uatn Applicant ALTER OR ADD TO MECH. q,00 BUILDING
>_ sat NOTICE. 'IO API'LICAN'1': If,al mr making this Certificate of Ex-
F• ? emPOon,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Libor Cards, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction Imuling agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this perrnit is issued(Sec. MICROFILM
3097,Civ C.f I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI IN UN IT ER 100,000 B.T.U.)7.50 ,
Limiters Address ELECTRIC
1 certify Ihut 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information iscorrect.I agree to comply with all city and county PLUMBING
oWinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
mby authorize representatives of this city to enter upon the BOILER-COMP IOwr 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(we) agrsx to save, indemnify and keep hamdess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3,Op CONST.TAX
may in any wa ccrue against a by in Lon en of the
g gof phi Y. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Signa con nnlinn4Conr etor Da
OFFICE COPY