6088 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT 1 DENTI FICATION ' _ PERMIT NUMBER
Y� aNLDING APPLICATION &PERMIT
ADDRESS IRC, - - 6088
�78� '. �'` �; BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S -
NAME , , - PLAN CHECK VALIDATION
DTY. ELECTRIC PERMIT FEE
PHONE 67
CONTRACTORS . � � OUTLETS-SWITCHES-RECEP .5.00/1.00
AA,�•.. /����(
LVE LIGHTING FIXTURES 5.00/.1.00
1-7
nooeeaTORS APPLIANCES 4.00
VN Axi kkftLL PHONE ^� PANELS S.00 DATE OF APPLICATION
ARCHITECT - PLAN.CHECK FEE P.C.NO.
OR - - SIGNS :6.00
ENGWEER '
LIC.NO, SIGNS TRANS.. 3.00
- ARCH,OR ENG. PERMIT.VALIDATION
AOCR Ess SPECIALCIRCUIT' -5.00 , ,
ZIP - EMP.METER OR POLE INS. 15.00 - -
APPLICANT'S J
ADDRESS MOTORS `SEE FEE'SCH.0 SE
' SERVICE CHANGE <t 10.00
20 F,OO LICENSED CONTRACTORS DECLARATION
v I hereby from that I am licensed under provisions of Chapter 9 '
Z iC ISSUANCE DATE
w
n Q (commencing with Section 7000)of Division 3 of the Business and Professions CO , BLDG. ELECT, PLG. MECH.
n n license is in full fort and eft c
Z z- 1 License s, •a_ Lic.Number 1 ,
Date Contractor uCVIN'
CE ¢ w Q ' OWNER-BUILDER DECLARATION BUILDING PERMIT
- A ° -
w O '1 hereby affirm that I am exempt from the Contractor's License MISC.= REFER T ORD INFORMATION
., y;
LL O Q Law for the following reason.(Sea 7031.5,Business and Professions VALUATION $/FT.
Code.Any city or countywhich requires a permit to construct,alter, PERMIT ISSUANCE 6.00 'w'
Q Q Q D Improve,demolish,or repair any structure,prior to Its Issuance,also ELEG,CONTR. LIC.NO. ELEC. +
O rc requires he applicant for Such permit to file a signed statement that TOTAL
u w m m be i5 licensed pursuant to the provisions of the Contractor'.,License I ^PERMIT TO
rzQ Law(Chapter 9(commencingwith Section 7000)ofDlvlsion 3 ofthe -
i O Business and Professions Code)of that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
I-m the basis for the alleged exemption.Any violation of Section 7031.5 TORIES TYPE CONSTR:
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):.
❑ 1,as owner of the property,or my employees with wages as -
BACK FLOW PROTECT. DEVICE 2.00 ,OC .GROUP .
their sole compensation,will do the work,and the structure is not UNIT
intended or offered for sale (Sec. 7044, Business and Professions . DRAINSr 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 F IXTUR ES-PER TRAP 4.00 • SO. T.FLOOR A A TOTA ACREAG
himself or through his own employees,provided that such improve-
ments arenot intended or offered for sale.if,however,the building- GAS-EA.SYSTEM-11NC.4 OUT,LETS 4.00
or improvement is sold within one year of completion,the owner- GAS-'EA.SYSTEM; 4 IEA.) 1.00 BUILDING USE '+
builder will have the burden of proving that he did not build of im- E M ` RES ''INO CON Pe Our.,
prove for purpose of sale.).. � INDUSTRIAL WASTE INTER. . ,"20.00 ❑ ❑ ❑ ❑
❑ d as owner of the property,he exclusively .7044,tBu with
licensed contractors :' construct the project(Sec. does Business LAWN SPRINKLERS-1 INC 5 V.B,- ,,,5.00 - ASSESSOHS PARCEL NO.
to
Professions Code:The Contractor's License Law docs not apply -
to an cts for
ouch projects with
ba contdS r improves thereon,andpursuant
who LAWN SPRINKLERS-OVER 5(EA.)'. 1.00
contracts for such projects with a conlrac[or(s)Bcensed pursuant to +s
the Contractor's License Law. - SEWER-SANITARY-STORM.EA.200ft/8.00 TRACT NO. PARCEL NO. :
.❑ I am exempt under Sec. ,B.&P.C.forthis WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE" ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 -
I hereby affirm that I have a certificate of to self-insure, ZONING -
or a certificate of Workers Compens. nsmamec,or a certified ENG.SITE NO.
copy thereof(Sec.3800,LabC
Policy No. Co Y•
0 ❑ Certified co lereby furnished. - FIRE SPRINK ENERGY T-24 -
Z ❑ Certifi copy is fled with the city inspection Division. - -
O Applica : MISC.- REFER TO ORD. y❑' N❑ J ❑ N❑ .
y' CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE. . 6.00 .FLOOD ZONE A.Lu.C.
COM
ION
CL 7 (This section need not be completed R'IA heFpermit is for one PLG.CONTP. LIC'.NO. TOTAL s'Y El-' N[] Y ❑ N[_]as
D Z hundred dollars IS 100)or Tess.) -
U O :1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. H mit is issued,1 shall not employ any person in any manner so as to
U bee a e�(1to the Workers' oro ns tion Lawry' alifor a.
Q lu Date =T.`�_A Orke `�y? BUILDING
Is. pp � ---'" ALTER OR ADD TO MECH'. 4.00
} m NOTICE TO APPLICANT: If,after ma ing this Certificate of Ex-
F ? ' emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
C.1 such,provisions or this permit shall,be deemed revoked. , AIR HANDLING UNIT(TO 10PED C.F.M.) 3.00 "
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 1000011EM.) 5.00 SEISMIC FEE
1'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. - MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U3 4.00
Lender's Name H EATI NG U N IT[OVER ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read his application and state that the above VENTILATION FAN ISINGL^E) 3.00
informationis correct. I agree to comply with all city and county PLUMBING
oNinances and state laws relating to building construction, and -BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of
thpurposes.s,city to enter upon
inspection above-mentioned property forr the BOILER-COMP Over 10b,CGO BTU)SEE FEE SCH. 'MECHANICAL
hi
(We) agree to save, indemnify and keep harmless the City of MISC.: 'REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ',PERMIT ISSUANCE '- 3.00 CONST.TAX
may in anyway accrue against said City in consequence of the •
granting of this permit ` /� MECH:CONT. LIC.NO. MECH. -
1�tu �LrTME TOTAL
Signature of Applicant/Conlmclor Data 's
OFFICE COPY,