4660 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING s �w APPLICATION & PERMIT 4660
ADDR Ess
.IV
Q oO ` BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
'f NAME(' CITY. ELECTRIC PERMIT FEE
J Y
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
` NAME
Ir k A'1�
LIC.No. 8 LIGHTING FIXTURES 5.00/1.00
S[
CONTRACT QA ��� PPLIANCES-RESIDENTIAL 4.00 -
corl
PHo AprAle-44 miONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 60_0 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 9�/
ADDRESNr$ MOTORS SEE FEE SCH. S
AODREssSERVICE CHANGE 10.00 noOLICENSED CONTRACTORS DECLARATION ..J
a v v I hereby affnn drat 1 am licensed under provisions of Cbapter 9 I55UANC GATE
y 2 m (commencing with Section 7000)of Division 3 of the Businessman BLDG. ELECT. PLG. MECH.
r H w Professions CoJ• anJ m license is in full Toner' d effect
se Class ❑ ❑ ❑ ❑
z O w Licen -r_?r Lie Nber
um
Q w Uatc_ E(.-y� Contract.,
t ,� BUILDING RMATIOPERMIT
K Q w¢
OWNER-BUILDER DECLA RA' INFORMATION
w REFER TO ORD
K
3 LL H I hereby,Rine. that 1 .m exempt 031.5 the iacw.oror,Licanxe MISC.- VALUATION SIFT.
F u o a Law for the following reason.(Sec.7031.5,Business and Prol'cs.vio^s PERMIT ISSUANCE 6.00
Code'.Amy city or County which rcquirts a permit to conztrucl,alh•e
G > 0 improve,demolish,or repair any structure,prior tonisms ntr.also ELEC.CONTR. LIC.NO. ELEC.
- ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n m a- he is licensed pursuant to the provisions of the Contractors License /�
ac Law(Chapter 9(commencing with Section 70000of DNision 3 of the PZ-uAf 6/,v CY
4
a Business and I'rol'essios Code)or that he is exempt therefrom a d T STORIES TYPE CONSTR.
PLUMBING PERMIT FEE
2 O
¢ I- $ the basis for the alleged exemption.Any violmion of Section 7031.5
d5- by any applicant for a permit subjects tire applicant to a Civil pcmdty ALTER-DRAIN& VENT-WATER (EA.) 4.00 40
of not more than five hundred dollars(5500).1:
❑ I,a owner of tire property,or my employees with wages az BACK FLOW PROTECT. DEVICE 2.00 oec.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,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 does such work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
mems are not intended or offered for sale,If,however.the budding GAS-EA.SYSTEM-I1NC.40UTLETS 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 tire ro
e burden of pving Him he did not build or im- RES IND CON PB Ont"',
prove for Pugrosc ll'z.la), INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner o1'the property,am cx Clusively contracting with
licensed contractors to construct the project(Sec 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
.ad Professions Code *rhe Contractors 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 projrctz with a co^traccurs)licensed pursuant In
SEWER-SANITARYV-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor,License Law.
0 lam exempt under Sec. .B.&P.C.for 11111 WATER HEATER W/VEN PAID 4.00
resin
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSA IION DECLARATION WATER TREATING 004;.00
1 hereby Atirm flat I have a certificate of consent to sell insure. MW
ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,car a certified
copy thereof(Sea.38 0,Lab C n /T
Policy No�j..}'Tri ompany �S t1((
Q q{ Certified copy is I eby'f nosh ed,C f /ff< I('4 FIRE SPRINK ENERGY T 24
_Z Z ❑ Certified 1 is fl the city Inspection division. MISC.- REFER TO ORD. Y0 NE) Y ❑ N[]
O nPpbCam
PERMIT ISSUANCE ,6.00 FLooO zorvE A.L.u.D
QC CIi R' t4lf f:t ENIi I 'ION 17EONI WORKERS'
W >_ 'O.NPYNSA MEN INSURANCE PLG.CONTI LIC.NO. PLG. AA..
d O (Phis section need not be completed if the permit is for one TOTAL Yv Y❑ NE] Y ❑ N❑
Z hundred dollars IS 000)or less.) ,-
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued. I shall not employ any person in any manner ss,as to
O W become:subject to the Workers'Com vp,aRmn Laws of California.
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} y NOTICE. TO APPL-ICAN'I': If,after making this Certificam of Ex-
F ? e,RpHon,you slnarld bccmnesuhject to the Workers'Compe^sution 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 10000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.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(See.. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00 PLUMBING vu
i.funnaliun is correct I agree to co n.ply will,all city and couty n
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
ordinances and state laws relating m holding construction, and
hereby authorise representatives of this city to enter upon lire BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City'of MISC.- REFER TO ORD.
Cupertino agai t Iliabilitica2pidgyI costs and expenses which CONST.TAX
maY
in an ey Ccr al said City in consequence of the PERMIT ISSUANCE 3.00
grantin the W MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
1 Signa ppliNRt/Conte for Date -
OFFICE COPY