6530 I U
j APVILICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
6ORDINc APPLICATION &PERMIT
.� np � BUILDING —ELECTRICAL—PLUMBING—MECHANICAL16530
NAMERE (,�/ PLAN CHECK VALIDATION
�. 1 OTY. ELECTRIC PERMIT FEE
:S�tL PHON
NAMERAcTDas UTLETS-SWITCHES-RECEP 5.00/1.00
16 Aar4
tic. r FIXTURES '- 5.00/1,00
r.LwTHa TORE- ��, ,s.A PP LI ANCES-RESIDENTIAL 4.00
' •� ADDRESS - '1yp
PHONE qq PANELS 5.00 DATEOF APPLICATION
ARRCHI CT - SIGNS6,00 PLAN CHECK FEE __FCNO
ENGINEER -
F LSC.NO, SIGNS TRANS. 3.00 _
ARCH.OR ENG. - PERMIT VALIDATION
ADDREEs SPECIAL CIRCUIT 5.00
zm ' EMP.METER OR POLE INS. 15.00
ADDRErvT$ • MOTORS SEE FEE SCH.
APPLIC
a
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
a v v I hereby affirm that I am licensed under provisimrsof Chapler 9 A A ( p 155 NCE DATE
I Z d (commencing with Section 70001 of Division 3 of the Business aaJ
a DG. EL❑CT. PLG. MECH.
Z F w i Profession- r� IDy liana is in full For jy cf /• C ' .
o In License ass _! yLT1—Lie. rambcr_'1
9 m �w Uate_, Conlredor_ '
a r E 8 8 �• ' BUILDING PERMIT
Q w OWNER-BUILDER DECLARATION INFORMATION
a`xt ;LL H 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
10 4 Law for the following reason.(See,7031,5,Businessand Professions PERMIT ISSUANCE 6:00 VALUATION -SIFT.
-al
Code:Any city or county which requires permit to construct.alter, e�
a ¢o improve,demolish,or repair any structure prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O te requires the applicant for such permit to fide a,igased statement That TOTAL PEO IT TO
d,w m n he is licensed pursuant to the provisions of the Contractor's License
R Z r Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation ofSection 703 L$ STORIES
Y.: TYPE CONSTR.
by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) ,
of not mora than five hundred dollars(5500).): . - -
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.u 5
then sole compensation,will do the work,and the structure is Rot
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 50.FT.PL as TGTAL CIIEAGE
himself or through his own employees.provided that such improve-
f mentsarc notintended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 IN C.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 Baa u5
s builder will have the burden of proving that he did not build or im- -
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑RESIND ❑N O �,
❑ I,as owner of the property,am exclusively contrxctins with e
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Calc The Contractor's License law does not apply ,
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmetods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA:200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under See. ,B.AP.C.for this WATER HEATER W/VENT 4.00
reason
Owner • Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSATION DECIARAT ION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING
or-a cerlifcate of Workers'Compensation Insurance,or a OcHiGeJ ENG.SITE NO.
copy thereof ISe-.3800,Iab.C.f
Policy No.—Company-
0
o. Company❑ Cetiliedcopy'isherebyfurnished. FIRESPRINK ENERGY T-24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applican l - V .N Y ❑. NF]
M to CERT IFICATE OI'EXEMPTION PROM WORKERS' -PERMIT ISSUANCE _ 6.00FLOOD ZONE - A.L.u.C.
UJ > . COMPENSATION INSURANCE I PLG.CONTR. LIC.NO. PLG. El
CL Y�ZD Z •('chis motion need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or It.I
UO 1"certify.that in the performance of the work foi which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL mit nt
is issued,I shall not employ any person in any ma r so ps to
U coNOTICIi e t Workcrs'C m o l of lilornu. .�
U a Dwe_,]1 aMvNiunt ALTER OR ADD TO MECH. 4,00 BUILDING
} w APPLI 'ANT: IL ter ma ing tbis CorliOcum of
Aarq
Z em,licn,you should becomesubject to the Workers'Compensation qpp LIANCE 4.00 PLAN CHECK '
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed invoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3-DO
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER I0=tF.M.) 5.D0 ' SEISMIC FEE D
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3197,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Namc HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's AJdrcss• - ELECTRIC
•snify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
j infoOratlon is correct. I agree to comply with all city and county 'PLUMBING
ordinances and state laws relating to building construdion, and
BOILER-COfJP(3 H.P.or100,000B.T.U.) 4.00
'hereby authorize representatives of His; city to enlcr upon the BOILER-COMP IOser 100,000 RTUI SEE FEE SCH. MECHANICAL
ubovrmentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.-, _ REFER TO ORD.
Cupertino against liabilities,judgments, .,is and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3,00
gmnlnn offhiyc, Jroll, LIC
/ MECH.CONT. .NO. MECH.,
•ZaS.•� — TOTAL . TOTAL -0�-
I/` 57g`n3f41�ot A ppppliciCH/C.o ractor Dale
• OFFICE COPY