2421 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BADDRE70 C?UILDING /VC
2421
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'6 /�/ QLrygr T 1� 'fa_2�'/>vF2� } x`h V-:d7�` /vl�,j. $��?y r fty ,+ i" PLAN CHECK VALIDATION
tHKdK Mir, • PHONE'?V'{OL� DTl tP rs ELECTRIC PERMIT 'S t,:! FEET
•ONTRACTOR'sn . OUTLETS•SWITCHES•RECEP 5.00/1,00
1 •I N E tf= o r - LIC.ND.
194/4P f LIGHTING FIXTURES 5.00/1.00 -
CONTRACTOR'ST",
/I I.fi. PPLIANCES-RESIDENTIAL 4.00
ADD[R'jfaS /\ -43
xJ � ITt 0- PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER �.�P LIC.c.ND. SIGNS TRANS.
ADDRESS
SS ENG. S.00 /•. PERMIjA'ALIDATION
ARCHE55 SPECIAL CIRCUIT ✓l VwY I/i/�CY
ZIP EMP.METER OR POLE INS. 15.00 AI#41-- gk EE1NJVL
APPLICANTS MOTORS SEE FEE SCH. (-4-11,19
AooREs 1,
/Q 7`/ 5 ejo SERVICE CHANGE 10.00 y -,r /n/,' I�
Woo LICENSED CONTRACTORS DECLARATION �D.�CIY/W CES
a u u 1 hereby affirm that I am licensed under provisions of Chapter 9 _ ISSUANCE DATE
w (commencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT. ,.PLG. MECH.
Ni Professions C z3 y license is in full for y ( - ❑ ❑ ❑
i v,D License Class Lic.Number
,A H j Date Contractor
2 r A,.i4 BUILDI NG,PERMIT.yzi,xt r
'. w a: OWNER-BUILDER DECLARATION 4 Cu �.IN F.ORMATI 0N`p;;94L4e)}
. 0AUMISC- REFER TO ORD
w vi I hereby affirm that I am exempt from the Contractor's License VALUATION 5/FT,
IL
Lawforlhe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
S Q G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. ELEC. 7
LL requires the applicant for such permit to File a Signed statement that
ss TOTAL PnERwMIT TO
he is licensed pursuant to the provisions of the Contractors License
w 'i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
E a Business and Professions Code)Or that he is exempt therefrom and OTY 4`]yy v>s.yyy PLUMBING PERMIT 5'`h .i` FEE
M i=- the basis for the alleged exemption.Any violation of Section 7031.5 ,,,e yY ,,s0.&Y)XI,I�vY+' +sero ,�r .,e�; +';�-fr `G's:=: STORIES TYPE CONSTR.
n by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.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
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 SM FT.FLOOR AREA TOTAL ACREAGE
w himself or through his own employees,provided that such improve.
ments are not intended or Offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
bGAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RE IND CON pe Other
pINDUSTRIAL WASTE INTER. 20.00
rove for purpose of sale.).
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.T 1.00
contracts for such projects with a contractons)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
reason❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificatpLaf �f+��insure. ZONING ENG.SITE N0.
or a certificate oaf Worku'Comgensatior�r ^c ,oLs r 77Trtificd
ropy thcreo a
P I ompany
Certs sed copy is hereby furnished. FIRE SPRINK ENERGY T.24
Z OJa.Cenifsed copy u filed with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant Y N Y N
~ m_ CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y E] N[3
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL'PERMIT FEE FEE SUMMARY
LL l- mit is issued.I shall not employ any person in any manner so az to -
U become subject to the Workers'Compensation Laws of California. 'Jt'
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 77
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
z 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAODC.F.M.) 5.00 SEISMIC FEE v
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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NamAddress Lenderss HEATING UNIT(OV ER 100,000 B.T.U.17.50
ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLET 3.00
information is correct. I agree to comply with all city and countyPLUMBING
Ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
Veiny authorize representatives of this city to enter upon the BOILER-COMP IOvar 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,judgments, costs and expenses which CONST.TAX
may in Away accrue a t said Ci y i conseq nee of Ilse PERMIT ISSUANCE 3.00
granting o lis pe L MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL''..'' �ffd0
Signatu of%pplicant(Conimetor late
OFFICE COPY