4591 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ONPERMIT NUMBER
BUILDING
APPLICATION & PERMIT_ _ 4591
ADDFESs / )
2 066,0 11f9rn 85�Lq BUILDING-ELECTRICAL-PLUMBING -MECHANICAL "'
JV
NAMERS „1/ PLAN CHECK VALIDATION
,,JJ "105y- �] D QTY. ELECTRIC PERMIT FEE
CONTRACTORS _ OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 5.00/1.00
ADNrRAcrDRs APPLIANCES-RESIDENTIAL 4.00
�•C-�O�NTqRAC /�((''yy
lLF A/y{ PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
NGINEER
LIC.No. SIGNS TRANS.. 3.00
ARCH OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADHESS
nv TEMP.METER OR POLE INS. 15.00 r�
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
¢,i /70
SERVICE CHANGE 10-00 / 43
o
Foo LICENSED CONTRACTORS DECLARATION
¢U U 1 hereby affirm that I am licensed under provisions of Chapter 9 ,GO VISSUANCE DATE
m
oHi Q a (Comencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w i Professions Code,and my license is in full force and effect. ❑
`� 0 m o License Class Lic Number
Date CoFt,.,tur NOV 19 .
a y i
¢ ¢w a OWNER-BUILDER DECLARATION BUILD( IT
o A " MISC.- REFER TO ORINFORMATION
X ; LL H I hereby affirm that 1 am exempt from the Contractor's License D
H u o e, Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUq,�
U,
et Code:Anycity orcounty which requires a permit to construct, ^OIY
¢ ¢ a O Improve,demolish,or repair any structure,prior t0 Its reliance.also ELEC.CONTR. LIC.NO. - ELEC, sA
a -7 f•+
o LL requires the applicant for such permit to file a signed statenumt that TOTAL o?.-/
w R,A he is licensed pursuant to the provisions of the Contractors License
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Sccl ion 7031.5 5 TYPF DON STR.
a 3 _ by any applicant I'or u permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER IEA.) q,00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my empI.yces with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the stt¢ture Is not
intended or offered for sale(Sec. 7044, Busimess.Rnd Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsare not intended or offered for sale,ll',however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
10
wner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of provng.tlmt he did not build or no-
prove I'or purpose of sale.). - INDUSTRIAL WASTE INTER. Y0 pp RES IND CON PB Other
❑ 1,as owner Of the ro,Hy,am exclusively cmtraciin,with 11 El �_ -❑
licensed contractors to construct the project(Sec. 7044,Business
and Professions Code:The Contractor's License Law docs not apply LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractous)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑nlam excm I it Sce. ,Is&P.0 'Or this WATER HEATER W/VENT 4.00
reaw __ C�,/�_
Date OwmL' WATER SYSTEM 4.00 Acc.DATE Ace FILE No.
WORK ERS'COMPENSATION DECLARATrot WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have u certificate ofcansunt Ixs rel Ginsure,
r u certificate of Workers Compensation Insurance,or a certified - ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab C.).
I'olicy No. Company
O ❑ Certified copy is hereby lurni,hed. RE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
FO Applicant MISC- - REFER TO ORD. yEl N1:1 Y ❑ NE]
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 c.
W M
> COPIiNSATION INSURANCE PLG.CONTR. _ LIC.NO. PLG.
11 ❑ ('Phis section need not be completed if the permit is for one TOTALY N Y E] N
Z hundred dollars IS 100)or less.)
U O_ I certify that in the purfurmancc of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall nom
t employ any person in any Insnnr s
co as to
Ow become subject to We Workers'Compensation Laws of Cahlornel, /
°• Date Applicant ALTER OR ADD TO MECH. q-pp BUILDING O
} Do NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f- ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
U u¢hlpins of the this
Code, you must forthwith comply with
permit shall be deemed revoked. FEE AIR HANDLING UNIT(TO 10=C.F-M.) 3.00
CONSTRUCTION LI'NDING AGENCY AIR HANDLING UNIT(OVER 10SWC.F.M.) 5.00 SEISMIC FEE ,Sp
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 Isstred(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name-
Lenders Address HEATINGUNIT(OVER 100,0006.T.U.)7.50 ELECTRIC p2 '�
I certify that I have read this application and state Illat the above VENTILATION FAN (SINGLE) 3.00
Information is correct. I agree to comply will, all city and county PLUMBING
\ ordinances and state laws relating to building consvuction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 4.00
hereby authorise rc Prescntu,ivcs of this city tD cooler upon the BOILER-COMP (Ove•100,000 BTU(SEE FEE SCH.
above mentioned property for inspection purposes. MECHANICAL
(We) agree m save, indemnify and keep Inrmlcss the City of MISC.- REFER TO ORD. _
Cupertino Inst liabilities,judgments, costs and expenses which PERMIT ISSUANCE CONST.TAX
y y 'ay a, ue against said City in cmoNquenc, of the 3.00
grantin f I s per ' . MECH.CONT. LIC.N0. MECH.
f j �7-��� TOTAL TOTAL , /'yam
Sig I rcut cont/Contractor Dole s
OFFICE COPY