3112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i.-1BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
RLDINc APPLICATION U PERMIT Z
ADDRESS
�O bO MAR
VIES
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
�./ OWNER'S PLAN CHECK VALIDATION
X NAME S �/ QTY. ELECTRIC PERMIT FEE
r ON ��
CONTRACTOR$
� NAME UTLETS-SWITCHES-RECEP 5.00/1.00
CJJ_LC. 7 LIGHTING FIXTURES 5.00/1,00
coNrflncroRs PPLIANCES-RESIDENTIAL 4.00
A D
CONTRACTOR
•N sPHONE s•Q/ PANELS 5.00 3 DATE OF APPLICATION
ARCHITECT SIGNS 6.QQ PLAN CHECK FEE P.C.NO.
OR
EN'
INEEP� II
r o. SIGNS TRANS. 3.00
ARCR.oRENc. - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
nv TEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS F H.
�T •�
0 V SS • S t1 qs1/0 SERVICE CHANGE 10.00
Z. 11 QL
0
0
o
Foo LICIiN58U COh'"TRACTORS DECLARATION
u u 1 hereby Affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business ant BLDG. ELECT. PLG. MECH.
H Professions Cod• and by license ism full IspyI h eK[�
Z 0 w License Class lib Lic.NumberaL'1 SS ❑ ❑ ❑
w H Date_)_ 1__-6..t_Contra<tu/jll.e�.ur&7co�
a :< E BUILDING PERMIT
M ¢ w a OWNI:R-BUILUIiR DECLARATION INFORMATION
MISC.- REFER TO ORD
K
3 LL H I hereby affirm that 1 am exempt from the Contractor's License VALUATION
to u_ o v, Law for the following reason.(Sec.7031.5.Bmimessand Professions PERMIT ISSUANCE 6.00 so
Code:Any city or county wh wit reyuiros a permit to construct,aI@q
aa improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. ,LIC.NO��� LEC.
se DLL requires the applicant for such permit to lite a signet statement thatTHE E LaT� 1e / _ TOTAL PERMIT TO
wse he is licensed pursuant to the provisions of the Contractor's License GG "V _
zi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthu
- a Business and Professions Code)Or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ =$ the basis for the alleged exemption.Any violation of Section 703 1.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant lea civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars IS5001J'.
O 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 Jo the work,and the structure is not
intended or offered lot 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 don such work FIXTURES-PER TRAP 4.00 so.FT.FrOOR AREA TOTAL.ACREAGE
. himself or through his own employees,provided that such imprmx,
memsare Hot through
,is oroffered employee,,pr lf.aded Ili ectile building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is uild within ono ye:u of completion, the owner GAS-EASYSTEM-OVER 4 (EA ) 100 RUILOtmG USE
builder will have lite burden of proving that he did not build or hit- . . .
- RES IND CON PO Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed eumractors to construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cod,: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.) 1.00
contracts for such projects with a contraclorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 Tflncr No. PARCEL No.
❑ lam exempt under See.-.H.&P.C.for this WATER HEATER W/VENT 4.00
reason
Um, Owner WATER SYSTEM 4.00 Ace.DATE ACC.FILE NO.
WORK ERS'CONIPIiNSAT ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby afllrm that I have it certifcule ul consent w scl Ginsure' ZONING ENG.SITE NO.
or u certificate ul'Workers'Compcns,Jinn Insurance,o certified
copy the�o�l Syc.3.8Q0�LS1},(: ST
P IicY No_ . �•(.•qCh
Q ❑ Certille opyI hereby�L) niched. FIRE SPRINK ENERGY T 24
z ❑ CV,fi, �+ LcsL�tl ly Ely i.. cill'm division. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N[
-
can A licant_ dC- G 1L cid
CC T CI.R'I'IFICA'1'1i 017 Ii XIiMPTION 1'RONI WORKIiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > CONHtFNSAI'ION INSURANCE PLG.CONTR. LIC.N0. PLG. v❑ N❑ Y ❑ N❑
CL 0 1'I'his section need not be completed if the permit is for one TOTAL.
Z) Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work fur which this per- DTV. MECHANICAL PERMIT FEE. FEE SUMMARY
UL H mit is issued, 1 shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
wDatc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} r6/) NOTICE TO APPLICANT: 11,after making this Certificate of IN.
� ? eniption,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 10AOQC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.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,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT IDV ER 100,000 B.T.U.)7.50
Loader's Add res, ELECTRIC -�
I certify that 1 have read thisapplication and state till the above VENTILATION FAN (SINGLE) 3.00
.
ordinances
n correct. I agree to comply with all city and county PLUMBING
ordinances and sate laws
relgree
toe to building constnnd co and BOILER-COMP(3 H.P.or 100,0006.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lose,100,000 BTU)SEE FEE SCH. MECHANICAL
ubuvrmentioned property Ibr inspection purposes.
(We) agree to save, indemnify and keep harmless the City Cl misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
cosy in an way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
Start Ibis ,coli' MECH.CONT. LIC.NO. MECH.
.3/ _?3 TOTAL TOTAL ��-•
X'I.SonaturTol'Applicant/C rooter [)are �✓ da
OFFICE COPY