3979 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IIDENTIFICATION PERMIT NUMBERING APPLICATION & PERMIT 3979
DO'
ESS
aoOREss BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
' � tloKFsh�rl _ _ _ _ _
WNER'S PLAN CRECK VALIDATION
NOEAV6A MgUG. (1p< <I�:CPQ�/OS' QTY. ELECTRIC PERMIT FEE
1 /'INC PHONE _
N�AMEaRppac^�roRs I� ??q UTLETS-SWITCHES-RECEP 5.00/1.00 V(J
�9M,i El�c-/ LIC.No, LIGHTING FIXTURES 5.00/1.00 -x
CONTRACTOR'S �'���^
aooREnss p /ly�v, APPLIANCES-RESIDENTIAL '4.00 -
`1 (alw 61�r /Q�Ae •vHONE PANELS 5.00 D TE OF APPLICATION
ARCHITECT
OR SIGNS 6.00 PLAN CHECK FEE D.C.N0.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00 6 �l-
ADDRESsTS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
'02 LICENSIiD CONTRACTORS DECLARATION -
a u w I hereby affirm Thal I am licensed under pr visions of Chapmr')
< a fmmmemmog with Sectors 70001 of Division 3 of the Reines and ISSUANCE DATE
H 7= Professions Co de and m license is in(all(u rce and e)l bct I'II BLDG. ELECT. PLG. MECH.
z o License Class= Lie-G Number.
4 m Date Contractor 60%Awr-e
ttr
IE ¢w a OWNER-BUILDER DECLARATION n;1sr BUILDING PERMIT
O a
MISC.- ��" RE ER TO ORD INFORMATION
w g 0 1 hereby affirm that I am exempt from the Contractors License
u o A Law for the following reason.(Sec.7031.5.Business and Professions _v VALUATION SIFT,
� - Code:Any city ercoumfy whlchrequireeupermittomnstrum alter. PERMIT ISSUANCE 6,00
rt ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
ou iL requires the applicant for such permit to file a signed statement that TOTAL 3
awe he is licensed pursuant to file provisions of the Contractor's License PERMIT TO
z a
Law(Chapter 9(commencing with Section 7000)of Division 3ofthe -
E i o Business and Professions Code)or that he is exempt therefrom and GTY, PLUMBING PERMIT FEE
CE r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a 3`= by any applicant for a permit subjects the applicant lou Civil penalty
of nALTER-DRAIN& VENT-WATER riot more than five hundred dollars(S500).): (EA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECTDEVICE 2.00
their sole compensation,will do the work,and the it
ructurc is not . OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors Licenm Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such improve-
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or hit- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove forpurpose ofsale.l. INDUSTRIAL WASTE INTERRES IND CON- PB Omar
❑ I,as owner of the property,an .t exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00
and Professions Code The Contractor's License Law does not apply asSEsSORS PARCEL No.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts forsuch projects with a iontolermis)licensed puramnt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00TRACT No. PARCEL NO.
❑ Iwo exempt under See_,H.&P.C.for this
asmh WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4.00
ACC.-GATE ACG FILE NO.
woRKERS CObIPISNSn1loN DECLA RATION WATER TREATING EQUIP, 4.00
1 hereby atlirm that 1 have a cerlificate of consent to sell:insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.CJ.
I'itlicy No. Company
O ❑ Certified copy is hereby famished.
Z 2 ❑ Cnrtil'ied copy is filed with the city inspection division. RE 6PRINK ENERGY T 24
Applicant MISC.- REFER TO ORD, Y ❑ N❑ Y ❑ N�
~ O PERMIT ISSUANCE
LUto CERTIEIGITEO'NSAiIPTINS PROM WO 6.00 FLOOD ZONE A.L.u,L.
CL COMPIiNSATION INSURANCE PLG.CONTR. 1.10.NO. PLG.
CL D (This section need not be Completed if Ile permit is for one TOTAL Y❑ NE] V NE]
U O hlmdRddoIIms(SI00)or Ies.) El
1 certify that in the performance of the work for which Phis per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued. I shall not employ any person in any ohanner H,as to
O W become,subject to the Workers Compensation Laws of Cahlbrnis.
Date Applicant
W
} DateNOTICE TO AI'1'LICAN3a If,a11er making this Certificate of Ex-
ALTER OR ADD TO MECH. 4,00 BUILDING
FZ emption,you should beeomesobject to the Workers'Compensafiun APPLIANCE 4.00 PLAN CHECK
provisions of tte Labor Code, you must forthwith comply wilh
U such provisions or fills permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE
CONSTR UCf ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work]or which this permit is issued(Sec. MICROFILM
3097,Cis,C,L HEATING UNIT(TO 100000 BTU ) 400
Lender's Name , . . . .
Lenders Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify tial I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
leinformation s n correct. I agree to amply with all oily and county PLUMBING
ordinances and stale laws relating m building conster u,CH and BOILER-COMP(3 H.P.or 100,0006.T.U.) 4.00
hereby authorize representatives of this city' to enter upon the
aboveementioned propenndemnispection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(we) agree to save, indemnify and keep harmlca the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ECONST. AXin any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00ng of this pont}yMECH.CONT. LIC.NO. TOTAL ��`nmcmr pate AL
OFFICE COPY