5050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
•
BUILDING-PROJECT IDENTIFICATION PERMIT NUMBER
emac 'APPLICATION & PERMIT 5050
'�Z An Doalsss ^ '
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWE 'S,
AM-E- PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
PHONE _3' IOII .
CONTRACTOR S. UTLETS-SWITCHES-RECEP 5.00/1.00 r'
A&VAII LW A4ILIGHTING FIXTURES 5.00/1.00
r,ONTencroH's I• APPLIANCES�RESIDENTIAL 4.00
CONTRACTOR
'
`Iv PHONE PANELS - 5.00 DATE OF APPLICATION
ARCHITECTr .. SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR "
ENGINEER
LC,NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS - MOTORS SEE FEE EH.
ADDRESS
SERVICE CHANGE _ 10.00
o ¢ z
Foo LICENSED CONTRACTORS DECLARATIONAID
a mo u ' I hereby affirm that I am licensed uuder.provisions of Chapter 9 . ISSUANCE DATE
�z a (commencing will%Section'70001.af Division 3 of tlm Business and
.y i I ref ssions COit it y license Is in full f0 B,kDG. -ELECT. P� MECH.
z i _ LI n CI l.•-/(Lt Lu Nun%her 'f[-,'Jtt• e(7S
g m UB 'Contractor
Mi pBU LDING PERMIT
¢ w OWNER BUILDER DEC R - �Of Cop6r�IPORMATION
w ; a- y I hereby affirm that I am exempt from the Contractor's License MISC.- .-REFER TO ORD
Luw far the following reason.(Sec.703 t.5,Busloess andProfess%uns .PERMIT ISSUANCE - 6.00 yA ATION SIFT.
Code:Any city orcounty whichreyniresapermit to construct,alter,
�/C.
QtoImprove
,demolish.or repair any Structure,prior tails issuance`,also ELECCONTR. LIC.NO. ELEC. /
e. m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO Q F
u w he is licensed pursuant to the provisions of the Contractor's License
r Z i l.aw(Chapter 9(commencing with Section 7000)of Division3of the S le-
< Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
fie
¢ r- o the basis for the alleged exemption.Any violation t ton cion malty STORIES TYPE CONSTR.
Lc FT by any applicant lorapermin subjects the applicwul naacivil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500),I:
LI1,as owner of the property,or my employeeswith wages us BACK F LOW PROTECT. DEV ICE 2.00 DCC.GROUP RES.UNITS
their sale compensation,will do the work,unit the structure is not
financed or offered I'or-sole (See. 7044, Business and P,ol'essions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '
Code:The Contractor's License Law does not apply no an owner of '
properly who builds or improves Ihereun,and who Joel such work FIXTURES-PER TRAP _ 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided fhal such improve-
mentsare not intended oroffered for sale.If,however,the building ' ! GAS-EA.SYSTEM-I INC.4 OUTLETS 4:00
or improvement is sold within one year of completion,lite owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im= RES `IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑. ❑
licensed contractors no construct the project (Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Cmumcmr's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctods)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,B&P.C.for this WATER HEATER W/VENT 4.00
reason
Dane Owncr - WATER SYSTEM - 4.00 - ACC.DATE ACC.FILE NO:
WORKERS'COMPEN,SATION IIECI.ARATION WATER TREATING EQUIP. 4.00
I hereby alfirm that bhave acertificate of consent tosell-insune, - ZONING ENG.SITE NO.
ar u certiGcac of Workers'Compmisution Insurance,or u cerlified
Copy Ihereol IS 3R00,'Lab',C.I. 1% "
Policy No. _ CoinpanY.-U/gL._G.OM(-�T-f't
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Cert ific 'opy is J wit fly inspection division.. MISC.- REFER TO ORD.
F�O. Appllca t Y ❑ No , Y ❑ N❑
w PERMIT ISSUANCE - 6.00
Cr - CIfRTI PICATIi OI'FIXE 'TION FROM WORKERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE I PLG.CONTR. LIC.No. PLG.
-'EL O 11'his section need not be completed if the permit is for one TOTAL - Y❑ N❑ Y[:] N❑
- D Z hundred dollars(5100)or less.) -
U 0 I certify that in the performance of the..Wlot which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any,person in any manner so as to
U b"rone subject to the Workers'Compensation Laws of California.
0'a Date-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT,If,after making this Certificate of Ex. -
1... ? emoion,you should become subject to the Wmkers'Com Pensatma APPLIANCE - 4.00 - PLAN CHECK Q 1
provisions of the Labor Code, you nus% forthwith comply with FEE
U sucl%Provisions or.this permit shall be Hemmed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE SO
I hereby affirm that lheie is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 2.00
the performance of-the work for which this permit is issued(Sec. MICROFILM
3097•Civ.C.). - HEATING UNIT.(TO 100,000 B.T.U.) , 4.00 Lender's Name HEATI NG UN IT 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I certify that I have read this application and state Ibat nhi•above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P,or 100,000 B.T.U.) •4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes:
- (We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
- Cupertino against liabilities,judgm nes; costs and expenses which _ CONST.TAX
may in any w' accrue agai iJ City in cmuequcnee of the - "' PERMIT ISSUANCE - 3.00
pial g,.flh pe nu it. MECH,CONT. LIC.NO. MECH.-
TOTAL TOTAL
• a ua plicant ntraetor Dmc '
OFFICE COPY,