2602 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PRMI H
RDILUING APPLICATION & PERMIT 2602
A.ORES20
1
(/D 1V hx BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME j ,/ CITY. -ELECTRIC PERMIT FEE
7 Y I�n PHONE
CONTERACTORS G�Q �/ UTLETS-SWITCHES-RECEP 5.00/1.00
RVIFIL/ Llc.rvo. JI 12D LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S Ljyb/ APPLIANCES-RESIDENTIAL 4.00
A ORE55 //
,D, �'(�. � • i�PHONE -_'S� 4rj,/ PANELS 5.00 GATE OF APPLICATION
RCHrtECT SIGNS 6A0 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS19
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS ('
SERVICE CHANGE 10.00 / D
o o LICBNSEU CONTRACTORS DECLARATION
Q u v I hereby affirm that 1 am licensed under prm'isions of Chapter 9 ISSUANCE DATE
m <H (commencing with Section 7000)of Division 3 of the Business and _ BLDG. ELECT. PLG. MECH.
F N z Prol'cssions Code n liccrec is in full for,• ❑
z o m - License CI' /- Lic.Nwnber ❑ ®` ❑
Q m F Date Contractor
a Y City of Cupertino BUILDING PERMIT
¢ ¢ w a OW'NIi R-BUILDER DF:CLA A' I N INFORMATION
MISC. REFER TO ORD
w3 LL F I hereby affirm that I am exempt from the Contract.",License vAwgn ON S/FT.
FLLOa Law for the following reason(Sec.7031.5,Businessand Pmlessions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
ce ¢Q Q improve,demolish,of repair any structute,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
on D LL requires lite applicant for such permit to lite a signed statement that TOTAL �T( PERMIT TO
a w m a- he is licensed pursuant to the provisions of the Contractor's Licenx C/
F - r Law(Cinque,9(commener,with Sectimi 7000)of Division3of the ELlYG7, ),A/4.
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F o the basis lox the alleged exemption.Any violation of Section 7031.5 STORIES TYPE COI
i ;° by any applicant for a permit subjects the applicant o a civilpenalty
ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 1,us owner of the property,or my employees with wages a, BACK F LOW PROTECT. DEV ICE 2.00 occ.GROUP RES.umrts
their sole compensation,will Jo the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner ot"
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT FLOOR AREA TOTAL ACREAGE
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- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or am.. RES IND CON PB Orme,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISee,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 or improves thereon,and who LAWN SPRINKLERS OVER 5(Eq.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
the Contractor's License Law. SEWER-6ANITAR V-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec .B,&RC,for this WATER HEATER W/VENT 4.00
sawn
Dain Owner WATER SYSTEM 4.00 gCC.DATE ACC.FILENO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby eftirm that I have a certificate of enm5eat to sell'-insure. - ZONING ENG.SITE NO.
or a certificate of Workers'Compen axon I n'•. I1
c99pyy�st��h of�SSG�J(q��0 Lab.C.). jjFO
O ❑ C-,]-led copy is tereb)'furnished. FIRE SPRINK ENERGY T-24
Z 2 O CeI ifj�l'.ropy is�I , wi the ID v.inspection division. MISC.- REFER TO ORD. ❑
O Applican��� //- HCS[- V N❑ V ❑ N❑
- CERTIFICA'1'I?017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU COMPENSATION'INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ v ❑ N❑
1 t❑ (Chis section need not be completed if the permit is for one TOTAL
Z) 2 hundred doll.rs IS 100)or Ivor
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
1L I- mit is issued,I shall not employ:my person in any readder so as to
O w become subject to the Workers'Compensation Laws of Cothlorrniu.
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICAN"I': 11,after making this Certificate of IA-
F ? emptier,you should become subject to Ore Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you ..it forthwith comply with FEE
U such provisions or this permit shall be decnhed revoked AIR HANDLING UNIT(TO 10)000CF.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IODWCF.M.) 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, HEATING UNIT(TO 100,000 B.T.U.) 4.00 Civ.C.l.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC �6`0
Lenders Address
I certify that l have read this application and State that the above VENTILATION FAN (SINGLE) 3.00
information d correct I agree I and ccomply with all city acounty 4.00 PLUMBING
ordinances cis Smtc laws relating to building const and , and BOILER-COMP(3 H.P.or 100,0008.T.U.)
hereby imtiori, represcnmtwes of this city to cut,, upon the BOILER-COMP (Over 100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save. Indemnify and keep harniless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in Rny way accrue against said City in em"echec, of the
gmntl g mills per MECH.CONT. LIG NO. MECH.
�I�'. _ J�h//��� /I/�� OTAL TOTAL
Si nature oL\pplicant//`C`o'ntractor [)ale
OFFICE COPY