3182 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
�BUILDINGPROJECT IDENTIFICATION APPLICATION & PERMIT
R
BUILDING 3182
KESS
/y\ •ANI A�Gw � BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 1 PLAN CHECK VALIDATION
""ME DTV. ELECTRIC PERMIT FEE
l.J PHONE
NAIVE CTOR's OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Lef-c} ICC , LIC No LIGHTING FIXTURES 5.00/1.0
AGUERAcroR's PPLIANCES-RESIDENTIAL 0
VODR Ess Nn
S PHONE 1-�I PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6 DO PLAN CHECK FEE P.C.NO,
OR
ENGINEER 3.00
' LIC.NO. SIGNS TRANS.
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
A OGRESS
ZIP EMP.METER OR POLE S. 15.00 n /�
APPLICANTS MOTORS SEE FEE
ADDRESS
SERVICE CHANG 10.00 p'
o o LICENSED CONTRACTORS DECLARATION
I heteby affirm that I am licensed made,provisions of Chapter 9 ISSUANCE DATE
R,01PE (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Co e, ed my license is in full for-•a 'I ell�'cy't -IqI
yy �yyt )L7.
fe License lass y II Lic.Numbs,, " 44� _ ❑ ❑ ❑
0 m H Uatc 0� Contractor -���-
Ka m s ///���``��''' G BUILDING PERMIT
E ¢ w V OWNER-BUILDER DECLARATION INFORMATION
K 0 B. I- I hereby affirm that I am exempt from the Contractor's License M C.- REFER TO ORD
a. 04 Law fur file following reason.(Sec.7031.5,BusincssaW Pm&ssioas RMIT ISSUANCE VALUATION
= - Code:Any city or county which requiresa permit to conshucL alter, 6.00
ar SE Q improve,demolish,or repair any structure,prior R)its issuance,also ELEC CONTR. LIC.NO. ELEC.
LL requires the applicant for such permit tD file a signed Statement lila TOTAL PERMIT TO
wmo he is licensed pursuant to the provisions ol'the Contractor's License
rzi Law(Chapter 9(Commenem,vonth Section 7000)Df Division 3 of OR,
a Business and Processions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT PEE
r c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ;m by any applicant for a permit subjects file applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 0 I
of not more than five hundred dollars($5001.):
❑ I,as than
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 xRucltrC is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,CC . 4-00
Code:1'he Contractor's License Law does not apply to an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 4.00 SD.ET FLOOR AREA TOTAL ACHEAE
himself or through his own employees,provided that such improvc-
mems are not intended or offered for sale.I1,however,the bwlding
- GAS-EA.SYSTEM-11NC.4 TLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OV E 4 (EA.1 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Du r
prove for purpose of sale.). INDUS TR IA L WASTE I ER. 20.00
❑ I,as owner of the properly,am cnchnively 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:'I'lie Contractor's License I.-docs cwt apply
to an owner of property who builds or improves thereon.and who LAWN SPR INKLER -OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed Pursuant to
the Contractor's License Law. SEWER-SANITA -STORM EA.200ft/6.00 TRACT NO. P eEL NO.
O I:un cxumnt under Scu. .B.&P.C.for this WATERHEAT W/VENT 4.00
reason
Date Owner WATER SYS EM 4.00 ACC.DATE ACC.FILE NO.
WORKE RS'CONIPENSATION DECLARATION WATER T EATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or payc.Ne�nifi,allc of Workers'Compensation Insurance,or a certified
❑, Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
N
z '¢�Certilicd copy is fled with the city inspection Aivizion. SC REFER TO ORD. Y ❑ NO y � N❑
Applicant-� � ,
rn CERT IFICATF OF I:XFMPI ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE�yo
DJ > CONI'ENS ATION INSURANCE PL .CONTE. LIC.NO. PLG. Y[:3 N
CL O (This section need not be completed if the permit is for one TOEAL
Z) Z hundred dollms(5100)orless.)
U Q 1 certify that in the performance of the work for which this par- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued.I shall not employ any Person in any manner o,as to
O w become Subject to the Workers'Comp,malion Lawsof California. BUILDING
a
Date Applicant ALTER OR ADD TO MECH. 4.00
} N
NOTICE prion TO APPLICANT: If,utter ora king this CeRrs'Coupecat,of Ex- 4.00 PLAN CHECK
Z em vesion You should become subject m the W forthwith
Compensation APPLIANCE .
ptnvis rovi all the his pe mit shall
you must forthwith comply with FEE
U such provisions or this permit shall bo Deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIRHANDLING UNIT(OVER 101000C.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,CiaC.l. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
II intimnatiun is correct I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
f� ordinances and state laws relating m building Construction. and
IrT hereby euthoriee representatives of this City to color upon file BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(we) agree to save, indemnify and keep hurmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ✓ CONST.TAX /
may in any way accrue again", id City in consequence of the PERMIT ISSUANCE 3.00
Onto f(Itis permit MECH.CONT. LIC.NO. MECH.
{� TOTAL TOTAL
2 Z
IX Si tarso , pplicant .o tau Da L.rl'� I�'l J'•+� / y
OFFICE COPY