17817 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - LISE.BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT,NUMBER
B.ILDI LD-I- LZ APPLICATION & PERMIT 781
ADDRESS o
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S t�yt,v PLAN CHECK VALIDATION
NAME•
E� PHONE753 ELECTRIC PERMIT FEE� 1 1
CONTRACT R
NA/ jy-� �� EI OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR APPLIANCES-RESIDENTIAL 4.00
ss C]]44��UU,,
PHONE PANELS 10.00 DATE OF APPLICATION
RA TEcr 0. PANELS (OVER 200 AMPI .20,00 PLAN CHECK FEE C.NO.
ENGINEER
r uc.No.'• SIGNS TRANS. 3.00
nooaess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP - EMP. METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. lN� l5�
ADDRESS h�
SERVICE CHANGE 20.00 ' VvM
w o O LICENSED CONTRACTORS DP:CLAflu
J
a U W I hereby affirm that I am licsnmd under pruvrs f cep r D ISSUANCE DATE
(commencing with Section ]0001 of Division 3 lh o si s
on n BL ELECT. P G. MECH.
H m i
License
Code.and my license is in(ell force a e
License Class Lie.Number .O
w F ° ' Dale Qntlracter $/ r•�,'.' 1 /} I EJu
y f u � - 1 BUILDINWA T
G PERMIT
¢ ¢ ¢
OWNER-BUILDER DECLARATION
¢ w u - INFORMATION
W'3 LL H I hereby affirm Ilml I am exempt from the Contractor's License MISC.- + •Hj RQFER;1TOImRD
uoj Lawlor the following reason.(Sec.7031.5.BusinessemJ l'ro(cssions PERMITISSUANCE 1000 IQ VALUATION S/FT.
Code:Any city or county which requires permit to construct,alter,
¢ p
improve,demolish,or repair any tnmlurc,prior le its\Sxuanc0.oleo ELED,DGNTR. LIC.NO. ELEC. -I Q D I I J tAe`J
O u requires the applicant for such permit to file a signed statement that TOTAL rte'
wLa$ he is LiermeJ pursuant to the provisions of the Contractors License PERMIT TO
0c Law(Charter 9(commencing with Section 70000ofDivision 3 ofthe
f 4 D Business and Professions Code)or that he is exempt therefron.and QTY. PLUMBING PERMIT FEE
¢ I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicam fur a permit subjects the applicant toa civil molly ALTER-DRAIN -WATER (EA.) 5.00 of not more than Five hundred dNlurs($5001J. V--'H
❑ I,as owner of the property,or my employs,,with wages as BACKFLOW PROTECT. DEVICE 4.00 oCC.GROUP REB.UNITB
their sole compensation,will do the work,and the structure Is not
im,ndsd or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,'AREA,COND. 5.00 n
Code:The Contractors License Law does not apply to an owner of
property who builds or improves.themon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
® himself or through his own employees.provided that such improve- _
...rets are not intended.,offered for sale If,lmwsver,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 M-1
or improvement.s sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 200 1482- - ,
8 L
builder will have the burden of proving that he did..o - . . .
t build or im- BUILDING USE
RES IND '.CON PB Other
prove for purpose of sale.(. INDUSTRIAL WASTE INTER. 30.00
❑ L as owner of the onstmeY.a exclusively, 7044,ting with Q ❑
licensed contractors to a Contractor's t
the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cods:The Contractor's License Law does not apply
to dr owner of properly who builds t, ilnprovev tnsed puand who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such License
L with a commemrts)licensed purwant m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORKHRS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of comcnt to self-insure, p
or a certificate of Workers'Compensation Insurance,or a'cerlil iod 3 ZONING ENG.SITE NO.
copy thereof l Sec.3800,LamCJ.
Policy No. Company
O ❑ Ceniliedmpyj lemhyfurnished. FIRE SPRINK ENERGY T.24
Z Z ❑ Cerlificd c s Iiled will. the c impectiun division.
F O APP1 ., ,n o MISC.- REFER TO ORD. Y NE] Y C] N[]
fY �' CL: 1.n ioP :m.f o. P Ofx 'ERs PERMIT ISSUANCE 10.00 - FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �'I � v N v N
CL D (This section need net be completed if the Permit is for one TOTAL _I
hundral dollars IS I Wh of less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H min is issued,1 shall non employ any peoon in any mann,,seas to
U become subject to the Workers'Compensation Laws of California. rT
O a Data Appli,,el ALTER OR ADD TO MECH. 5.00 BUILDING IC6 •-
} W NOTICE TO APPLICANT: If,after making this Certifi vat of Ex-
F ? ernplom,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK _
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this pennit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONS'fRUCI']ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE 833
I hereby afOmo tlmt there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM _-
3097,Civ,C.).. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT ER 100,000 B.T.U.)9.50 O
Lender's Address ELECTRIC
I C
1 certify that 1 have orad Ihis applical oli and slate that the above VENTILATION FAN (SINGLE) 4.00
• intorn.ation is correct. I agree to comply with all city and county PLUMBING b�
ordinances and %ate laws relating to building construction, and BOILER-CDMP(3 H.P.0r1.00,000 B.T.U.) 6.00
above-eby above-mentioned
ro,sarl nl olives of this city es enter upon the BOILER-COMP (Over IOQODOBTU)SEEFEESCH. MECHANICAL
hr •- mnthery p rep,rtylotrasp of this
putty to
(We) agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD. 37 n
Cupertino eget liabilities,judgments, costs and oxlxnscs which PERMIT ISSUANCE 10,00 QU_j CONST.TAX / OI r74
May
in any .sous against N(d City in conwyue • of he 1 TTT
renting o s permil. MECH.CONT. LIC.NO. MECH.
TOTAL L, 5 TOTAL `j LjA
c p tun Contractor Date ��
OFFICE COPY
- l