4661 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. { BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
a o� APPLICATION & PERMIT
BUILDING 4661
ADDRESS
/ 0 N - BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
<I OWNER'S PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE
S y'!} PHONE"
�4 CONraacoRS OUTLETS-SWITCHES-RECEP 5.00/1,00
LIc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR's
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
S l
Zu (/rlQ QY( (0(/ff PHONE PANELS 5.08 GATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO, SIGNS TRANS. 3.00
Ane H.OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLIOANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 ? ✓�CZ
M o LICENSED CONTRACTORS DECLARATION Y/ C
a o� I hereby affirm that I am licensed under provisions Of Chapter!) ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
F w z Professions Cod ul ry license is in full Puree and ateg ❑
z o m- License Class_�JL1.`Lit.Number_ Il�j-
Hr u Datc_;�_y� Conlr ctor
a Y s - BUILDING PERMIT
E Ix w u OWNFi R-BUILDER DECLA RA INFORMATION
F
a H 1 hereby uffmn that 1 am exempt from the Contr:atur's LicensL• MISC.- REFER TO ORD VALUATION $/FT.
H .. of Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
E vo R, Code:Any city or county which requiresu permit toconslruct,alter, ELEC.CONTR. LIGNO.
a a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
sOM requires file applicant for such permit to file a Signed statement that TOTAL PERMIT TO
K
m Ie he is licensed pursuant en the pith'ssects of the Contrnvision License
Hie Law(Chap(er9(commm�cingWith Section 7000)ofDivision3of(he
- Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Lo ;m by any applicant far a permit subjects the applicant tuaciv.1 penalty / en
of not more than five hundred dollars(5500).): ALTER-DRAIN -WATER (EA.) 4.00 V
❑ 1,as owner.1 tile pro perry,or it,employees with wagon as BACK FLOW PROTECT. DEVICE 2.00 6CC.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 Low dues not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees.provided flat such improve-
ment,
mGrove-menu are not intended or of fend for sole.If.however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00
or improvmnent is sold within'one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 O BUILDING USE
builder will have the burden of proving that he did not build or in. RES IND CON PB On,n
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property',am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to emxtruct the project (Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: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 coutraetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ian,exempt under See ,B.&P.C.for this WATER HEATER W/VENTM for, 4.00
reason
s .
Date Owner WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKERS'COMPENSA'rION DECLARATION WATER TREATING Vir .00
I hereby affirm thet 1 have m certificate ol'cmnsenl to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensw ion Insurance,or a certified
copy thereof 3a ,Lab.C.). of SwA�/�Y(b
e.
1'nlicy Nopt enptlny�a C � sulky ER VUVUILIIIU
O }a Ce'lotdcopylshen,lb If stied.OF « FIRESPRINK ENERGYT-24
'Z ❑ Certified p is I the city inspection division. MISC.- REFER TO ORD.
Oz-) Applicm,( Y❑ N❑ V ❑ ,N❑
F- y PERMIT ISSUANCE 6.00 FLOODZONE A.L.u.c.
CER' 1'I�i OP EXENIPTI )N PROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ¢�pa ❑ N❑
�• O (This section need not he completed if the permit is for one TOTAL Cl Y Y ❑ N❑
Z hundred dollars IS l 001 or less.)
U O 1 certify' (bat in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
1- ml( isissued, I shall not employ any person in any manner so as to
Ow become subject to the Workers'Comns
peation Laws of California. BUILDING
ED DateApplicant ALTER OR ADD TO MECH. 4.00
} m NollCE "f0 APPLICANT': IL uftur nuking(his Certificate of Ex-
emption.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 Pettit shall be donned revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction Icnding agency tin EXHAUST HOOD (WITH DUCT) 2.00
me 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
Lenders Name HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
Icer(ify that lhave read this application and late that the above VENTILATION FAN (SINGLE) 3.00
0 information 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
ordinances and start laws relating to hudding construction, a,,,
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mmrtioned property for inspection purposes.
(we) agree to save, inlet mfy and keep harmless the City of MISC.- REFER TO ORD.
Cupertino n st Nati- •s udgments, costs and expenses which CONST.TAX
cony in y y r gains( said City in comsaqucnct of [it, PERMIT ISSUANCE 3.00
grant's of :P n MECH.CONT. LIC.NO. MECH.
.. TOTAL TOTAL
Signator of Applican ontractor `Date V
OFFICE COPY