25940 ¢ z.
00
QU
z wU
V, Q N
�pz
p z F o
¢5WU
is 3
H u o 4
J
r
ac Xc a
is
e
H z a
io
f i o
A. 3 -
,40
O
Z
N
L'>
W -
ao
Uo
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALI_ POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
$ PERMIT
BUILDING -ELECT R_I CAL* PLUM BING-MECHANICAL
PERT NAPPLICATION QA
tJ `j'
PLAN CHECK VALIDATION
-
PATE OF APPLICATION
BUILDING
ADOREss
OWNER'S
NAME '/
PHONE rL�/2
QTY. ELECTRIC PERMIT FEE
VJNTRACTOR'S
NAME
ej- LC.ND. �0'1�
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES' 5.00/1.00
C,ONT ACTOR'S
ADOREss
�f' Z, /,?4!5-F PHONE2�`21-67
"APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00`
ARCHITECTSIGNS
ENGINEER
- Lie NO. -
6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS:3.00
AARCDDRESS ENG
SPECIAL CIRCUIT+ 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
- ZIP
-
ADDRESS -
AS
MOTORS -' SEE FEE SCH.
4
l 0�7
SERVICE CHANGE - 10.00.
LICENSED CONTRACTORS DECLARATION
i
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full fandor; f e
License Class Lic. Number
ISSUANCE DATE
BLDG.
❑
ELECT.
El
PLG.. MECH,
Date Contractor
I BUILDING PERMIT
j INFORMATION
-+
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law forthe following reason.(Sec. 7031.5, Business and Professions
Code: Any city or coomy which requiresa permit loconstruct, altar,
improve, demolish, or repair any structure, prior 10 its issuance, also
requires the applicant for such permit to file a signed Statement that
he is licensed pursuant to the provismr, of the Cmllmctor'S Lice+se
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC. - REFER TO ORD
PERMIT ISSUANCE '6.00
VALUATION
r
'
5/FT.
ELEC. CONTE. LIC, NO.. ELEC.
- _ TOTAL
DTV. PLUMBING PERMIT FEE
- PERMIT TO
V
'
STORIES'
TYPE CONSTR.
the basis for the alleged exemption. Any violation of5ection 7031.5
by any applicant for a permit subjects the applicant too civil penally
Of net mole than five hundred dollars (b500).):
ALTER -DRAIN &VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
-
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
4ms are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
'
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00
i
R(!improvemem is sold within one year of completion, the owner.
builder will have the burden of proving that hu did not build or iin-
prove for purpose of sale.).
❑ I', as (,.at of the property, am exclusively contracting with
GAS- EA. SYSTEM -OVER 4 (EA.) - 1.00.
-
BUILDING USE -
RES IND. CON PB Oshar
❑ ❑. ❑ ❑ ❑
INDUSTRIAL WASTE INTER. , 20.00
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
SPRINKLERS - 1 INC 5 V.B. 5.00
-
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contmc¢N(s) licensed pursuant to
the Contractor's or such
License law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL N0.
❑ l am exempt under Sec.., B,&P.C., lin this
-
WATER'HEATER W/VENT 4.00
reason
Date Owner
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKE-RS'COMNiNSATION DECLARATION
1 hereby affirm that I have a certificate ofeonsent tO sel Ginsure,
or a Certificate of Workers' Compensation Insurance, ora certified
-
ZONING
ENG. SITE NO.
-
copy thereof ea J8�00, Lab.C.I
Polley NeSd$onq+uny.�EL(-Tj,
❑ Cctlllied copy is hereby (umisimd' -
8 CeNifl��ed,��cIo�p�' i.,' led wt0` he 'lpy� ., ctLon sls+on.
Applicant �+R�- /f---H--t-r
"
FIRE SPRINK
Y ❑ N ❑
ENERGY T.24
I Y ❑ N❑
MISC- REFER TO OR D.
CERTIFICATE 017 EXEMPTION FROM WORKERS'
. PERMIT ISSUANCE 6.00
FLOOD ZONE
A. L. V.C.
. COhIPEN$ATION INSURANCE,
(This section noed not be. completed If the permit is for one
Y ❑ N❑
Y ❑ N❑
PLG. CONTE. - LIC. NO
-
PLG.
TOTAL
hundred dollars ($100) or leas )
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any mannerso as to
become subject to the Workeli Compensation Laws of California.
Date Applicant
NOTICE '10 APPLICANT: If, after making this Certificate of Ex-
QTY. MECHANICAL PERMIT P ' EE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE- .0
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
"
cinquNn, you should become Subject to the Workers'Compensation
provisions of the Labor 176de, you most forthwith comply with
such provisions or this permit shall be decided revoked.
AIR HANDLING UNIT (OVER 10= C. PWY9 U
SEISMIC FEE
,
CONSTRUCTION LENDING AGENCY.
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.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00 Al -
Leader's Address
Lender's Address -
H EATING UNIT (OV ER 100,000 B.T.Ud7.50
ELECTRIC
' '
I Certify that I have read this application and slate that the above
VENTILATION FAN (SINGLE) 3,00
-
+Informxt ion is correct. I agree to comply with all city and county
Tances and state laws relating to building construction, and
• 'PLUMBING -
BOILER -COMP(3 H. P. or 100,000 B.T.U.) 4.00
BOILER -COMP IOver 100,000 BTUI SEE FEE SCH.
MECHANICAL
,uJ
` v
,;y authorize representatives of this city to enter upon the
"above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save; indemnify and keep harmless the City of
Cupertoo against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
igr ting o(this pe it -MECH.
CONST. TAX
_
PERMIT ISSUANCE 3.00
CONT. - - LIC. NO.
MECH.
_
AApplicant/Con
_
TOTAL 7
TOTAL
Signa are actor Date
OFFICE COPY