6896 APP,LICAIVT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
/ BU LDI NG PROJECT I DENT[FICATI ON PERMIT NUMBER
UoNsc
APPLICATION & PERMIT
ATREs T�" � BUILDING — ELECTRICAL—PLUMBING—ME—MECHANICAL
U 6896
DINNER'SA PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE`
y
corvTRAcroRs UTLE -SWITCHES-RECEP 5.00/1.00
NAME ^
/- LIGHTING FIXTURES 5.00/1.00
ADDRESS oFs PP LI ANCES-RESIDENTIAL 4.00
CONTRA L d/
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
u
- s..No. SIGNS TRANS. 3.00
ARCH.OR ENG. S•PECIIALC.•IRCUIT PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15-00APPLICANT S MOTORS SEE FEE SCH. /
ADDRESS
SERVICE.CHANGP.) 10.00 G�
woo LICENSED CON']RACTORS DECLARATION /
G o u 1 hereby affirm that 1 an;licensed under provisions of Chapter 9 ISSUANCE GATE
y rt i (commencing with Section 7000)of Division 3 of the Business and V V.. BLDG. ELECT. PLG. MECH.
F N' Professions Code and my license is in full force and Hf- t. _
License C�l__aus{{��jj ..�Lim,Number -1`� /-'S p l El ❑ E]w t w Datc1lL2 Contractor C1t`I 01 CUPef 1
¢ r / ;BUILDINGIPERMIT
a ¢w¢ OWNER-BUILDER DECLARATIONr
a0.H. MISC.— - REFER TO ORD ""INFORMATION
So
; LL I hereby of firm that I am exempt from the Contractor's License - vaLUATIory $/FT.
.. o sc Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
— Code:Any City ur county which requiresa permit to construct,alter,
a ¢G 0 improve,demolish,or repairany structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �f
—O¢ requires the applicant for such permit to file a signed statement that _ TOTAL y.-/ PERMIT TO
u w he is licensed pursuant to the provisions of the Contractor's License p -
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he Is exempt therefrom and QTY. PLUMBING PERMIT FEE "TEM
re F Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
c- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500)):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole conhpensation,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 docs 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,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsareHot intended or offered for sale.l(,however,the building GAS-EA.SVSTEM-11 4.00
r improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BuaowG USE
builder will have[he burden of proving that he did not build or ire- RES IND CON PB Other
prove for purpose of sale J. INDUSTRIAL WASTE'INTER. 20.00
❑ 1,as owner of the property,ren exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I 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 nr proves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) ' 1.00
im
amtmcts for Such projects with a contmetoos)licensed pursuant to
the Contractor's License Low. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I:un exempt under Sea ,B.&P.C.I'or this WATER HEATER W/VENT 4.00
reason
Owner Date - WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKFRS'COMPENSA'IION DECLARATION - WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to sell insure, ZONING ENG.SITE NO.
n a Certificate of Workers'Compensation Insurance,or a certified
copy thereof`(Sec.3500,Lab,C)
Policy No. Company
O ❑ Certified copy shereby furnished. FIRESPRINK ENERGY T 24
Z ZO A�IcCn'One v fil� with Oe lepers. ' inion. MISC.- REFER TO ORD. y❑ N❑ v ❑ N❑
iry - PERMIT ISSUANCE 6.00 FLOODZONE A.L.uc.
LU CERTIFICATE OI°FA%1i1 PT ION FROM WORKERS'
11J COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Y❑ N❑ v❑ N❑
CL 0 I'1 his section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.) 11 1, s,4' ' '✓
U Q I certify mat in the performance of[lie work for which this per- OTY. - MECHANICAL PERMIT ac FEE .'-iF,EE,vSUMMAflY
LL P mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. BUILDING
U LU Date Applicant ALTER OR ADD TO MECH. 4.00
a
} US NOTIC17 TO APPLICANT: If,after making this Certificate of Ex-
f— Z emplion,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=41F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.EM.) 5.00 SEISMIC FEE
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. MICROFILM
3097,Civ,C,), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC ']
Lender's Address OC� v
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply with all city and county BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating m building all
and cconstruction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 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 any way accrue_againsbsaid-City-iI psequence of the PERMIT ISSUANCE 3.00
graph. f is pe n MECH.CONT. LIC.NO. MECH.
_3 TOTAL TOT-ALs, "
Shgna ure of Applicant/Contractor Date
OFFICE COPY