17820 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
AG UJT 5 'APPLICATION & PERMIT
ADDRESS G
^O
�DCDCO C� S C1 _, BUILDING -ELECTRICAL-PLUMBING-MECHANICAL r
OWNER$ 1/ PLAN CHECK VALIDATION
NAME f�
f12Q �C` ,7 DTV. ELECTRIC PERMIT FEE
ONE
CONTRACTORS �� at»1i •-U � UTLETS-SWITCHES-RECEP 10.00/1.00
NAME /TK/L
Luc.No. LIGHTING FIXTURES 10.00/1.00
CONTRA OR'Srj' G DMp APPLIANCES-RESIDENTIAL 4.00
AOOREss (L,��l
PNONE PANELS 10,06 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER "
uc.No. SIGNS TRANS. 3.00
ADDRESS ENO - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
AS21F EMP.METER OR POLE INS. 20.00
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
cco LICENSED CONT RACTORS DECLARATION >
a o. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h < w (commencing with Section 7000)of Division 3 of the Business and _ BLDG ELECT. PLG. MECH.
o z Professions Code,and my license is in full force and effect.
z o v2- License Class Lic.Number i
ow t w Date Contractor
¢ m s I _ BUILDING PERMIT
X ¢ OWN 17 R-BUILDER DECLARATION
a 0.U - O REFER'TO ORD INFORMATION
se ; a- h 1 hereby affirm that 1 am exempt from the Contractor's License (LI VALUATION
LL D ¢ Law(or the following reason.(Sec.703 L5.Businessand Professions ERM NC 10.00 - $/FT.
� - Cade:Any city or county which requiresa rermitloconstruct,alter, //''y)!E'y�/��
¢ Q p improve,demolish,of repair any structure.prior to its issuance,also C ONTR. LIC.NO. ELEC. 1 IPS I -71UJJ
a. O m requires the applicant for Foch permit to(ilea signed statement that �� TOTAL PERMIT TO
E
re he is licensed pursuant to the provisions of the Contractor's License
FZI Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
¢ Business and Professions Code)or that he is exempt therefrom and QTY. / PLUMBING PERMIT FEE
¢=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a pnTrit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of not more than live hundred dollars($500).): ALTER- AJ_H
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.. DEVICE- 4.00
their Sole compensation,will do the work,and the structure is not DCC-GROUP RES.UNITS
intended or Offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,00 �_ J - I ,
Code:The Contractor's License Law does not apply to an owner of
property who builds or impraves thereon,and who dues such work FIXTURES-PER TRAP 5.66 51y FT,FLOOq AREA TOTALACREAGE
himself or through his own employees,provided that such Improve-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 laa Fm%
or imprmrem<nt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden Of proving that he did nor build or im- RES IND CON PB Omer
wproperty,prove for purpose of Cad .)..). INDUSTRIALWASTE.INTER. 30.00 �❑ ❑ ❑ ❑
❑ 1,as owner of the pperty,am exclusively'eomracting with
licensed coutracmrs m c.mDuct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B: 6.00 ASSESSORS PARCEL NO.
and Professions Cod,:The Contractor's Liana Law does nut apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contract,to, .,h oi,w,with a contruct.no Ii,,nV d pursuant to
the Ccntractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.ABC.for this WATER HEATER W/VENT 6.00 .
rcasnn
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKE RS'COMPIiNSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to selhinsum. ZONING
or a certificate of Worker,'Compensation Insumncu,of a certified ENG.SITE NO.
copy the'.0s,"3800, b.CJ.
Policy No. C eany
❑ Certified LOPyi crmy famished. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified cep a filad with city spection division.
O Applic t q L1�(�/�//I� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CCN Cl: CITE OP EXBMPI'lO POhlWORKERS' PERMIT ISSUANCE 10.00 FLOODZONE AL.U.C.
LU > COMPENSATION INSURANCE:. PLG.CONTR. LIC.NO. PLG. '(Q_
CL O (This section need not he cunmlclnl if the pennit.is To, one TOTAL Y❑ N E] Y E] ry❑
ZE Z hundred doll..IS 100)or h,,T
U O 1 ecrtify that in the performance of the work fur which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any p,rnon in anyanume,so as In
become subject to the Worker:Compensation Laws of California
a Date Applicant q y4
ALTER OR ADD TO.MECH. 5.00 BUILDING
} m NOTICE TO AITI.CANT: If,after making this Certificate of Ex-
F Z en bion,you should become subject to the Workers'Compenvation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Codc, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1OPMC.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDUNGLENIT(OYER 10=C.F.M,1 6.00 SEISMIC FEE _
I hereby affirm that there is a construction'Iending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work fur which this permit is:swan](Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
headier',Name HEATING UNIT(OV ER 100,0130 B.T.U.)9.50
Lenders Address ELECTRIC r'
I twit,that l have,cad this application and irate tlm the above VENTILATION FAN (SINGLE) 4.00
e -
ordinances and state laws relating to building construction, and BOILER-COMP Q H.P.or 100,000 B.T.U.) 6.00
information is correct. I agree to comply with all city and county PLUMBING 5)
hereby authorire repreyfor inspection purposes.va if this city m enter upon the
above-mentioned property for BOILER-COMP (Cher 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agmc rp save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino wSI liabilities,cujudgments, costs and expenses which CONST.TAX �7
truly in a ay accrue agitans said City in consequ ce the PERMIT ISSUANCE 10.00 a' r �2.• /
rantin this pmit. MECH.CONT. LIC.NO. MECH.
OTALTOTAL
entre o(Applicant Contractor Uatc �
OFFICE COPY