4601 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•. BUI LD1 NG PROJEC NTI FICATIONPERMIT NUMBER
BUQDING APPLICA & PERMIT .
e T AOOREs���� 4601
/L BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S O PLAN CHECK VALIDATION
""S�A Co _� DTV. ELECTRIC PERMIT FEE
DONTRAL:W;rEz UTLETS-SWITCHES-RECEP 5.00/1.00
NAME //`�//tltl'
✓Ef Jt jo// e 60p"C.NO. ;?,0 O30 ILIGHTING FIXTURES 5.00/1.00
"ONADUrRacra s APPLIANCES-RESIDENTIAL 4.00
LOS N!>G26S ONE �HESS 3 PANELS 5.00 DATE OF AP PLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C,NO.
OR
ENGINEER
IC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG
ADDRESS . SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00 ��^
APPLICANTS MOTORS SEE FEE SCH. /1
ADDRESS
/
' SERVICE CHANGE 10.00
02 LICENSEE)CONTRACTORS DECLARATION /0
a v U I hereby Alirm'I bar I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the linsiness and
n'O' Professions CoJ n, I nse is in fu 11 lilt BLDG. ELECT. PLG. MECH.
z o w License Class Lie,.Number_ U_ ❑ ❑ ❑
o z r o pare /-8 f._Contractur_ Tem
a y q 6-NCW`i"
It t OWNER-BUIL IN
UECLARA ION _ BUILDING PERMIT
Of O MISC.- REFER TO ORD INFORMATION
w LL w I hereby al firm 0n21 1 am exempt from the Contractor's License VALUATION 8/FT.
o a Law for the following reason.(Sec.703 1.5,Business unJ Professions -PERMIT ISSUANCE 6.00
a Code'.Anycityorcounty which requiresa permit toconstruct,altef,
improve,demolish,or repair any stricture,Priof to its issuance,:dFq ELEG.CONTE, LIQ N0.
ELEC.
la
- O a, requires the applicant for such Permit to file a signed statement that TOTAL PER IT TO
u w m n he is licensed pursuant to the provisions of the Contractor's License
r z i LawI(Chapter 9(commencing with Section 7000)of Division 3 of the ML
- 4 Ih;slness and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
is the basis for[lie alleged exemption.Any violation of Section 7031.5 STORIES TYPECONSTR.
age by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
Pliant more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
tlreir sole com pensatiun,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:'rhe Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.Provided what such ibuildi g
Lnrs are nm intended on emrcdliesale,provided
that r.suhebuddlgg GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within oac year of cwnpletiun,tie owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int RES IND CON Pe Cou",
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to comtracl the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
add Professions Codi 1'he Contractor's License Law dues now 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 conUaclor(s)licensed pursuant to
SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ l am exempt under SL.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date owner WATER SYSTEM 4.00 Acc.oarE ACC.FILE No.
WORK ERS'COMPENSATION LFCLARATION WATER TREATING EQUIP. 4.00
I hereby annum that I have a certificate ofn
consent to nclf-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy'he
r 0 Lab.0) '�yy
I' Icy Nn�/(( /�m puny'-IAS-�O��F
O ❑ Ccrlllied cop is hereby furnished, FIRE SPRINK ENERGY T 24
Z ❑ Certifiyl �yny Is ied with Joe city xPection j� ismo" MISC.- REFER TO ORD.
"O. Applicant_.G./f-I-�[+f✓-47"44C�J�Y Y ❑ "❑ Y ❑ N❑
W C,Ii RTIFICKfIi OF fi KEMPTION'FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.D.
CC LU >_ COMPENSATION'INSURANCE PLG.CONTR. LIC,NO. PLG,
CL O ('chis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or IessJ
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner us us to
� w becumasuhjcat to the Workers'Conhpens'ation Lwsot California. BUILDING
Uawc Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE"r0 APPLICANT: If,al',er making this Certificate,of lis.
F 2 emption,you should become subject to the Workers Connpeoitioo APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such Provisions or this peimil shall be decnhcd revoked. 2 AIR HANDLING UNIT(T .F.M.) 3.00 (7
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00QF.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lot EXHAUST HOO H;DUCT) s 2.00
the perkonnance of um IN
work for which this Permit is issued(Sac. HEATG UNIT 0,000 B.T.U.) 4.00 MICROFILM
3097,CIv.CJ.
Lender's Name HE UNIT I' U.17.50 ELECTRIC
Lender's Address •^
I cert ily what I h:We read this applicmion and stale that the shove VENT(LATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and courtly -BOILEF,'-COM4 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby mtlhoria representatives of This city it) enter upon the BOILE -COMP ( Per 100,000 BTU)SEE FEE SCH. .1a MECHANICAL
abovomcntioned property for inspection purpoxs.
(We,) agree to save, imlenmify and keep h,Ruoc,s the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in Consequence of file PERMIT ISSUANCE 3.00 3
gran' f This pmmiL MECH.CONT. LIQ NO. MOTAL
Q' 3 , S TOTAL
�Mgj!U of Applical'iMl7ontractor Late
OFFICE COPY