4282 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i
BUILDING PROJECT IDENTIFICATION �EITNUMBERHDILDING APPLICATION & PERMIT0
ADORESS U
2ogop MMR-ISI AVE BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
. 5Y V A coy-i"A�Y ,HONE q9G-99G
CONTRACTOR
'AME UTLETS-SWITCHES-RECEP 5.00/1,00
NAME
ec.NO. LIGHTING FIXTURES 5.00/1.00
A DONESOrors PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LAC.NO. SIGNS TRANS. 3.00
ARCH.oR ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANT SMOTORS SEE FEE SCH. S
ADDRESS
SERVICE CHANGE 10.00 ,(p
FOO LICENSED CON"TRACTORS DECLARATION PA
Q U u 1 herchy affirm that I am licensed under provisions of Ch.mC,9 ISSUANCE DATE
m a w (commencing with Section 7000)of Division 3.1 the Business andD E{�(�5 PLG. MECH.
F wi Professions Code,and my license is in full force and effect. F1{1 ❑ ❑
z o ,n - Lic reac Class Lie.Number �f
0r w Dem Contractor
a "f C hl Of (BµyrgMlCa PERMIT
w a OW NIi R-BUILDER DIiCLA RA"TION ��I �j}RIN ATION
woAD MISC.- REFER TO ORD
LL H. 1 hereby affirm Ihat 1 am exempt from the Contractor License VALUATION SIFT.
FLL0JLaw for the following reason.(Sec.703L5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city orcounty whichrequiresapermil to construcl,alteq
Q 0 improve,demolish,or repair any structure,Prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-o u recu res the applicant for such permit to the a signed statement that TOTAL PERMIT TO
u w re he is licensed pursuant to the provisions of the Contractor's License
Fza Laos Chapter 9(commerem,with Section 70000ol'Divisiom 3 of the EM OJH[ /�/d+Ql
CITY. PLUMBING PERMIT FEE
Business and Professions Code)or that Be Rexempl therefronh and
H o the basis for the alleged exemption.Any vinlalion of Section 7031.5 STORIES TYPE CONSTR.
i3m by any applicant fur a permit subjects the applicant toacivil Penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I.as owner Of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.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,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 Ed FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,Provided that such improve-
ments mselfo nulimenId, or employees,ttered for provided
that s,che building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of conhpletion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving ti . . .
min he did not build or - RES IND CON PD Omer
Jovy for purpose of'rile.I INDUSTRIAL WASTE INTER. 20.00
1,us owner of the property,am CxClaslvcly contracting with 1:1 El. 1:1 11 ❑
liedcontractors to construcl the project(Sec.7144,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not amply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. A`C.for Ill., WATER HEATER W/VENT 4.00
reason
Dale 7 nor WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMP:NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-inNue, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lath E.).
Policy No. Company
Q ❑ Cetlified copy is hereby furnished FIRESPRINK ENERGY TQ4
Z Z ❑ Certfled copy is Filed with the city inspection division. MISC.- REFER TO ORD.
Applicant Y ❑ N❑ Y ❑ NO
H yA
� - CF RTI FICA'TIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE .L.U.C.
W > COMPENSAT'ION INSURANCE PLO.CONTR. LIC.NO. PLG.
D (Phis welion need not he completed if the permit is for one 1.TOTAL Y[:] N❑ v E] N❑
Z hundred delta,,(5100)or less.)
U O I ttrlify ,,at in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
, P mn
unit is issued,I shall not employ any person in any maner so e,to (f`
UW become subject to the W'orkeni Compensation Laws of California. BUILDING 6Q3
Dale Applicant ALTER OR ADD TO MECH. 4.00
} N NO1'ICIi TO APPLICANT': If,after making this Certificom oI'Es-
♦- Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you rust forthwith Comply with FEE
U such provisions or this per...it shun he deemed revoked. AIR HANDLING UNIT(TO 10,0000F.M.) 3.00
CONSTRl1C'I'ION LENDING AGENCY
AIR HANDLING UNIT(OVER 10SMC.F.M.) 5.00 SEISMIC FEE
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.Cie C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATING ON IT(OVER 100,000 B.T.U.17.50 ELECTRIC
Lender's Address
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-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
oNinances and orWu laws agree
ting m comply
with i construction.nand
hereby authorize representatives of this city to enter upon the BOILER-COMP (Con,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep luuniless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ,0 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this pcmlil. as MECH.CONT. LIC.NO. MECH.
l�-c (/1�e��/gy/`T'J' I �p�j3 TOTAL TOTAL 97
Signamr ApplicuntlC mmcl DatC , ✓
OFFICE COPY