4270 APPLICANT TO•FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION PERMIT NUMBER
BUILDING - APPLICATION & PERMIT R �'] 0
AooREss fF I
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OwINER'S - PLAN CHECK VALIDATION
NAME
M�C -2-Y -1e;0OTV. ELECTRIC PERMIT FEE
1 1 J HONE
NAMERADTDRs UTLETS-SWITCHES-RECEP 5.00/1.00
160b �e - LIC.NO.U�1a LIGHTING FIXTURES 5.00/1.00
AD.TRAOioRs S• Os�z APPLIANCES-RESIDENTIAL 4.00
AOORE55 /�yy��c�j .�y-y�
en Pl-( oajF2LS0/I- 'PHONE O!/z'0(0S0 PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER -
uc.rvo. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS 15.00
APPLICANTS
MOTORS SEE FEE SCH.
'DURESS
SERVICE CHAN E 10.00 AI®
w o o LICENSED CONTRACTORS DECLARATION I�•(t IVa'/
A, u u I hereby affirm that I am licensed under provisions of Chapter 9 URNCE DATE
w "' (commencing with Section 7000)of Division 3 of the Business and B ECT. PLG. MECH.
I- i Professions Code�arr�1���yyy license is in full fgrp�.yld�f��c�.�
goy- License Class S:�S'_1..-Lie.Numb
er��o- ' els ❑ ❑
y Dale - ContraclolfSC'-Q /s
¢ ¢ ¢ OWNER-BUILDER DECLARATION VIran L INC PERMIT
¢ w u INFORMATION
w ;
. 1 I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
ATION WET.
IL m a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 vnLU
Code:Any city or county which requiresa permit toconstrucl,alter,
2. , < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC.
- D¢ requires the applicant for such permit to file a signed statement that TOTAL q ' PERMIT TO
eL w m
i hit he is licensed pursuant the provisions of the Contractor's License /W �.
F z Law 9(commencing wSection 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r D the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
E. 5-; by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars 155001.1: I
❑ I,as owner of the property or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 "_SjdeneA- I
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD,FT.FLOOR AREA TOTAL ACREAGE
menta are not
ownemred for sale,
IL ed that however,
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
cents are not intended or offered for sale.II,however,[hc howner-
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove
of will have the burden of proving that by did not hold or int. RES IND CON PB Omer
ti- prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ L as owner of the property,am exclusively contracting with ❑ ❑ ❑, - ❑. ❑
licensed contractors IO construct tile project(Sec.7044•Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professionslons Code:The Contractor's License Law does not apply
to antr owner of property who builds tr improvesthereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&I'.C.iia this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 " ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm [bat 1 have a certificate of consent to sell-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof(Sq(:4800,Lab.C.j, � ��a � (� �
Policy No. mpany�7����C.�
C) ❑ Certified copy ishereby funlisllcd. FIRE SPRINK •ENERGY T 24
Z 2 Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. v ❑ N❑ v
❑ N❑
O Apcunt
CC W CERTI FICATE OF:EXEMPTION I7ROM WORK QRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
n' O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
=1 Z hundred dollars($100)or less.)
U O I certify that in the performance of the work for which[Ills per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL Emit is Issued.I shall not employ any person in any manner so as to
U y become subject to the Workers'Compensation Laws of Culllbrnla.
Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Es- -
I- ? eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 - PLAN CHECK -
provisions of lire Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10f.1000.F.M.) 3.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE
1 hereby offirnl 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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cle.CJ.
Lender's Name-
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.17.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with allcity and county PLUMBING.
ordinances and stale laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.1 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Can,100,000BTUISEE FEESCH. 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,judgments, costs and'expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit. _ MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL5D
Signature of A pplwan DContractor Date
OFFICE COPY