0336 APPLICANT TO FILL IN INFORMATION WITHIN R9D LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I C,�_Tl ON PERMIT NUMBEQ V
BUILDING APPLICATION & PERMIT 0.336
.DDF E. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
CITY ELECTRIC PERMIT FEE
P.0.12� 4W .1
�'C'nACTOH S OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
,fNTRAOTOR S -RESIDENTIAL 4.00
G CHESS APPLIANCES
PANELS
-2 5.00 DATE OF APPLICATION
PLANCHECK7 P.C.NO.
OR SIGNS 6.00
ENGINEER Lm.NO. SIGNS TRANS. 3.00 .PERMIT VALIDATt:0 N
ARCH.08 ENG. 5.00
ADD SPECIALCIFICUIT tr-
HESS
Z" FrEMP.METER OR POLE 15.00
AllLmANT, ZZ716f I I --
�OORESS I Iut;p hVI: MOTORS _.SEE SCH.
'q hrg�aA I CA Q SD*70 SERVICE CHANGE '�O
Z q 2;;�
0 0 LICENSED CONI RACrORS DECLARATION V00
I hereby affion that I am licensed under Provisions ofChapter 9 ISSUANCE DATE
z. (commencing with Section 700NO)of Division 3 of the Business and
BLDG ELECT. I PLG. MECH.
m Professions Cose,and my license is in full force and effect.
Z Z0 L �3i cerise Class-Lie boubs, El 11 1:1
2 as, ale_Cootractor�
' ; i '� BUILDING PERMIT
a, OWNER-BUILDER DECLARATION
ROA , INFORMATION
is I hereby afflon that I am exempt from the Contractor\Li,,o,c misc. REFER TO ORD LUATION $/FT.
0 < Law far the following nc,,smi.(Sce.7031.5, PERMIT ISSUANCE 6.00
Code:Any city or county which requires a Permit to construct.alter,
so> 2 improve,demolish.or repair any structure,prior to its issuance,also
L PERMIT TO
ao M R 0 1
E requires the applicant for such permit to rile a signed staten C2_4 E.U.
ient that /_/eT T�
W is he is licensed pursuant to the provisions or[lie Contractor's Lieviise ;1�
Law(Chapter 9(c.romencirg,vith Section 7000)ofDivision 3 of tli4'
Ban nm and Professions Code)or that he is exempt thireftom and CITY PLUMBING PERMIT FEE 01A C_
c hinsis for the alleged exempt ion.Any violation of Section 7031.5 STORIES T
the CONSTR.
T by any applicant for a permit subjects the applicant toa civil penalty
"fnol more than five hundred dollars($500L), ALTER-DRAIN&VENT-WATER (EA.) 4.00
0 1.as owner of the property,or my employees with wages as
their sole compensation,will do the work.and the structure is not -BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS,
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.DO
Code The Ccotracto r's Liccr,c La.does ,of apply to �owner.1 -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.1�FLOOR AREA TOTALACREAGE
himself or through is own emplo,ces,provide,that smh Improve- -
..is in-,Not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-1 INC.40UTILETS 4.00
.1 Hoprovement is sold within one year of completion.tire owner- -GAS-EA.SYSTEM-OVER 4 (EA.) 1.00
bo Ider will have the burden ot provitig that he did not build or iT, BUILDING USE
prove for purpose of sale,). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB ov�o
a 1,A, w.,or the property,am e.'stuMvely contracting with - 0 0 11 1 E] 11
liwcn�' contractors to construct the protect(See.7044,Busiress LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and s d
Professions C.dc:The Contractor',License Law does Hot pply
to an cwTv,of......erty who builds or A,coim,and who LAWN SPRINKLERS-OVER 5(EA.) 1.()o
contracts for such projects ,ith ir ccotractoos)licensed pumnant to. SEWER-SANITARY-STORM EA.200WIB.Do TRACT NO. PARCEL NO.
the Comnimo,',Lee.La..
0 am exempt under See B&ITC:for I li'i,
ri,,.i, WATER HEATER W/VENT 4.00
Owner WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby afF,m that I hii,,it enifleme of cons,ein to.wlf-instire,
or a certificate of Workers'Compeiisation I risuranc,-or a certifed ZONING ENG.SITE NO.
copy thereof(Sec.3800.Lab,C.).
Policy No.-Company
0 0 Certified copy is hereby Himished. FIRE SPRINK ENERGYT24
Z Cl Certified copy is filed with the city in....(I.... REFER TO ORD. !I Y EJ N Y [] NE]
0 A,plic,,,t _�M I-SC
CC CERTIFICATE.OF EXEMPTION 17RONI AORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL,U.C.
LU COMPEN�ATION INSURANCE PLG,CONTR. LIC.NO,
0 ITIPP, med ..I be completed if (In, permit i� for i,c TOTAL y IN 0 y 0 NEJ
Z hundred dollars IS 100)or h,sx.)
0 0 1 certify that in the peyfor-morce of the work for which this Per- FEE FEE SUM ARY
CITY. MECHANICAL PERMIT
UL Ntit is issued,I slitill Out CHI,ftp�Z.%o is mium,,r so to
u tb=�tc the W.,k,, Ii '"ahfz".
0
O_ [)at Applicant BUILDING
0 �NOTICE TO APPILLAN7 y Her making this& i ii c Of Ex- - ALTER OR ADD TO MECH. 4.00
cNiption,�ou should becom& bject to the Worken'Compensation APPLIANCE 4.00 PLAN CHECK
,00sions of flic Labor Code, you must forthwith comply with - FEE
such Provisions or this pemlit shall lie dect,od revoked. AIR HANDLING UNIT(TO 10MOC.F.PVL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10JOODC.F.M.) 5.00 SEISMIC FEE
I hereby affin, that there is a coostrucitsion jerming agency for EXHAUST HOOD (WITH DUCT) 2.00
the Performance of the work for which th permit I,i...ned(Sec. - 'MICROFILM
3097,Ci,C.). HEATING UNIT(TO 100,DOO B.T.U.) 4.00
Lundcr*s Nam
Lcndc,',Address HEATING UNIT(OVER I 00,ODO B.T.017.50 ELECTRIC
I certify that I have read this application dnd state that the above VENTILATION FAN (SINGCO 3.00 __ //
orcormilio, I, correct I agree to comply with all city.,,it county. PLUMBING
ordinances and state laws relating to buildii Ror-100,000B.T.U.) 4.00
hereby authorize representatives of this city 1013,000 BTU)SEE FEE SCH.
above-mentioned property for inspection pur,,, MECHANICAL
(We) agree to save, indemnity'and keep haomi. the City of MISC.- REFERrTO ORD.
Cupertino against liabilities,judgments, Costs I'll - CONST.TAX
may .or any way irccirue against mid City in consequence of the PERMIT ISSUANCE 3.00
ranti.,of this Permit MECH.CONT. LtC.NO. ECH.
TOTAL TOTAL
pl,mitme col ApplicarliC Date I IM
OFF=COPY