5492 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
UILDING PROJECT IDENTIFICATION .`9 PERMIT NUMBER
B
lJ APPLICATION & PERMIT'
BUILDING-ELECTRICAL-PLUMBING--MECHANICAL 5492
OWNERS
CONTRACTOR'S �. to
- PLANf�f)Chf1U.IDATION -
NPk �C\ 'nTV. 'ELECTRIC PERMI11 T •' kFEE rr^ VV
h PHONE " 11984
I
OUTLETS-SWITCHES-RECEP 5.00/1.00 F{
LIL NO_2-._)I4 LIGHTING FIXTURES 5.00/1.00
f•GNTRACTOR's APPLIANCES-RESIDENTIAL 4,00 city is Cupertino
AOOIi[55 I�� I - •Q���x yIL) �' CnD
\��\\ PRONE&? 3010 PANELS - 5.00 - DATE OF APPLICATION
` A CHITECT a SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER -
uc.No. SIGNS TRANS. `3.00
ARCH.OR ENG. PERMIT VALIDATION.
ADDRESS SPECIAL CIRCUIT '5.00
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADOnnss MOTORS SEE FEE SCH. /
- ✓ I'�kN1
SERVICE CHANGE 10.00
o o' LICHNSED CONTRACTORS DECLARATION
u,witirm that I am licensed under provisionsofChapterS
H 4 H nmmencing wilh,Seetinn]0001 of Division 3 of the Business and BLDG. EL T. PLG. MECH.
dessions Code,and my license is in full fn,trrf tfLa/tCJ-? ❑ RC
Z o= - icaue Class.Lic:Number _ G--' ,
9 z f2 o Uutc Contract.,
a x s r BUILDING ERMIT,
¢ ¢ st OWNER-BUILDER DECLARATION
a o a U ,.. INFORM TION.`'
X ; ,�y 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD -
F LL o J Law for the following reason.(See 7031;5,Business and PmteWcas - PERMIT ISSUANCE VALUATION $/FT.
Code',Any city or county whiny requiresa permit o its Mon
allcq
6.00
Q Q Q 0
improve,deim.Il5I1,Of fep'dlf any SINCIUR,prior 10 its ISSUanee.also ELEG.CONTR. LIC.NO. ELEC.
to
: u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X$w he is licensed pursuant to the provisions of the Contractors License
rZ > Law(Chapter 9(commencing wit It Section 7000hofDivision 3 oflhe
0 Business and Professions Code)or that he is exempt therefrom and` CITY. PLUMBING PERMIT FEE
M IhCIIusis for thealleged exemption.Any violation of Section 7031.5 S.TO.RIES TYPE CONSTR.
n ;m by any applicant fora permit subjectsthe applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five Imndred dollars(5500).):
❑ [,as owner of the property,or-my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUPRES UNITS
their sole compensation,will do life work,and(he structure is not
intended or offerCd for'sale (Sec. 7044, Rosiness and Professions DRAINS-FLOOR,ROOF;AREA,COND. 4.00
Code:The Contractor's License 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 TOTALACREAGE
y in... or through hiS own employees,pmvidcA the such imFrom-
'm
rove- 'GAS-EA.SVSTEM-11NC.40UTLETS 4.00 _
F� mrents are not intended or offerCd for sale.If.howeveq the building _
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or on. . . RES IND BUIPB Omer
prove for purpose of sale.). , INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property am exclusively contracting with _ 1:1 E] - 1:1 ❑
licensed contractors to Construct the poject(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS7SVARCEL NO.
and Professions Code:The C.mracmr's License Law does not apply
to an owner of property who builds or improves thereon.and who LAW_ N SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for such projects wish 11 contractor1s111censed pursuant to
the Coutractur's License Law. SEWER=SANITARY-STORM EA.200ft/8.00 TRACT NO: PARCEL NO,
❑ lam exempt under sec. ,e.&P.C.for this WATERHEATERW/VENT 4.00
reason
Ownc���,��'�� (p/�� !1 I WATER SYSTEM' ' -- - 4.00 ACC.DATE ACC.FILE NO.
�t/�N'tl1tK1iRS'COMPIiNSA1'ION DECLARA IOT N " � WATER TREATING EQUIP. 4.00
I hereby affirm that I have a cerlificate of,omxoi to sell-insure, ZONING ENG.SITE NO.
.r a certificate of Workers'Compensation Insurance,or a ccrtiffed _
copy Ihe,Cof(Sec.3800,Lab.(\\��
olicy . N� 2 �i(` q 1 - W
PNoany1A1 WSJ
Q', ❑ lied cop is eby fora FIRESPRINK ENERGY T-24
z - Ccrtil,
is will t 'peer n division. _ _
Applies __ MISC, flEFER TO ORD. Y'❑ a❑ Y ❑ ' N❑
- ~ PERMIT ISSUANCE 6.00 DD
CIiRTIPICA'I'li OP IiXIiMI'TIUN PROM WORKIi RS' FLOOD ZONE A.L.U.C.
LLI J COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG.
• CL O ([his action recd.not be completed if the permit le`for one • - TOTAL Y❑ N❑ Y❑ N❑
2 h hundred dollars(S100)or less) - _
C) O I certifythat In IIIc performance of the work for whah thus Lr - - a
p p CITY.
- MECHANICAL PERMIT FEE' FEE SUMMARV�a"' ;
LL H nal Is issued,I shall not employ any person in any manner ns as I.
U become subject to the Workers'Compensation laws of California.
O n Dan, ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} m NOi'ICIi TO APPLICANT: If„after making this Certificate of lix-
H Z emption,you should become subject tri the Workers'Compensation APPLIANCE I' 4.00 PLAN,CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10000 C.F.M.) 3.00
CONSTRUCTION L17NDING AGENCY- AIR HANDLING UNIT(OVER 10000C.RM.) 5.00 SEISMIC FEE
I Iwmby affirm alar (here is a construction lending,agency for EXHAUST-HOOD(WITH DUCT) 2.00
the perfnrmaoc pt lire work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING'UNIT(TO 100,000 B.T.U.) -4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
1.cnder's Address ELECTRIC
I certify that I have readrilis application and slate that the above VENTILATION FAN (SINGLE) 3.00
.infnrmution is Corrucl. gree to comply with all'city and county - PLUMBING
•�, onlinanacs and s' aws ,doing to building construction, and ' BOILER-COMP(3 H.P.or 700;000 B.T.U:) 4.00
hereby auth " e representatives of this city to enter upon the BOILER-COMP(Ova,100,000 BTU)SEE FEE SCH. MECHANICAL
above..' oned property for inspection purposes.
rag save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
pertino sins[ ' bilines,judgments, costs and expenses which PE MIT ISSUANCE 3.00 CONST.TAX -
only in any wuY xc ore ag lef said CITY in consequence of,the
g lingofth 'Pm it.' MECH.CONT. - LIC.NO. - MECH '�
TOTAL' TOTAL
of Applicant/Contractor ate
•OF,F ICE COPYs.