5412 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING. APPLICATION & PERMIT 5 412
ADDRESS .:
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Ale 4 &eAAAL
OWNER'S / PLAN CHECK VALIDATION
• ""mE ren/ - . DTV. ELECTRIC PERMIT FEE
/ H.NC
NrRACTOR S UTLETS
-SWITCHES-RECEP 5.00/1.00
NAME q
T41
sec.Na. ®� IPG LIGHTING FIXTURES 5.00/1.00
r. TRACT Rs PPLIANCES-RESIDENTIAL 4.00
A ooREss
1PANE1,S 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHE,FEE P.C.NO.
on
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00 /1
APPLEANT'S MOTORS. SEE FEE SCH. J-0
ADDRESS C
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION PAIC
IC u I hereby.fluor Thal I am licensed under provisions of Chapter 9 ISSUANCE DATE
H Q w (Conmencmg with Section 7000)of Division 3 of the Business and SEP 6
91ZZ;I
MECH.
Z O m - License Class Lfc.Number-
ateContractor .. City of Cup Bun
a: tc w ¢ OWN[R-BUILDER DECLARAS30NINFORMATION,', 'f` a
REFER TO ORD -
w3 u h 1 hereby affirm that I um exempt Gam the Contracmrs License C.- y N p$FT.,
Hu00a Law for the Hollowing rcason.ISec.7031.5.IiusinessunJ l'nrfessiuns PERMIT ISSUANCE 6.00 /q' A/7J�„[ � 9V/�
Code:Any city or county which requires a permit to construct,alter, /7///(///Ny/
rt ¢a 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /0's O¢ requires the applicant for such permit to file a signed statement that TOTAL /0S 'p GPM
w$LL he is licensed purswm to the provisions al the Contractor's Lotare
H z i
Law(Chapter 9(Commencing with Section 7000)of Division Sol the
¢ cosiness and I'rofussions Code)or that he is ext nnpt therefrom and DTV. PLUMBING PERMIT FEE
¢H m the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
u ; _ by set applicant rare pernitsdollars thcepplicantmacivil penalty ALTER-DRAIN -WATER (EA.) 4.00 y �
oI not mom than lira permit dollars the applicant
.1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GR UP REjUNITg
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:'fire Contractor License Law docs not apply to an owner of
' property who builds or improves thenen,and who docs such work O FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mems arc not intended or offered for sJle.11,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
r improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) -1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- E IND CNG PB Omar
prove for purpose ofsxlcJ. INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors 10 construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORBPARCELNO.
and Professions Code:'I'[it Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVE IEA.I 1.00
contracts for,such projects with a Contractions)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-S A.200ft/8.00 TRACTNO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this ! WATER HEATER W/VENT 4.00
redsa
Owner Date WATER SYSTEM 4.00 ACC.DATE ACCFILENO.
WORK I SRS'COMPENSATION D17CLARATION WATER TREATING E*%,,,&0 4.00
1 hereby affirm that I have a certificate are....Sent to self-marc. Lity
ZONING ENG.SITE NO.
or a certificate fif Workers'Compensatiominsurunce,o r a certified
ropy thereat(See.3800,Lab.C.). ' 3
Policy No. Comp:my_
604
O Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
Zz CrRiticd /p�y is a with the Ry "., division. MISC. REFER TOORD.
CCW CERT'IFICATIi OF EXEM ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD Z E p.W -
LU >_ -_ -,NSA1'10 INSURANCE PLO.CONT H. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL 6-- Y❑
Z) Z hundred dollars IS 100)or les")
U O I certify that in the performance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY;, .. dA`x
LL H mit is issued,1 shall not employ any person in any manner so as to /
Ow become subject to the Workers''Compensation lawsof California. BUILDING G p0
rete AppIiCmA ALTER OR ADD TO MECH. 4.00
} N NOTICE:TO APPLICANT: IL utter making this Certificate of F.x-
? Certo on,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 permit shall be deemed revoked. AIR HANDLING UNIT(TO 10DWC.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.M.) 5.00 SEISMIC FEE
1 hereby elfin.. that Were is a rnnstruction lending agency I'.. EXHAUST HOOD (WITH DUCT) 2.00 ..1 �•
the performance of the work for which this permit is issued(Sec HEATING UNIT(T B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lcudcr s Address
-
I certify that I have read this application and sone that the above VENTILATION S GL 3.00 •3 "'� -
information is correct.I agree to comply will,all city and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-CID P(3 . .or 100,000 B.T.U.) 4.00
hereby authorize representatives o1this city m enter upon the BOILER-COMP f0ee 0 ® EE SCH. MECHANICAL pZ
above-mentioned property for inspection purposes.
(We) go" to save, hulenmify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 - CONST.TAX
ory in any way accrue ugaiust aid City in to... ucnce oC the
gmnlin ofthis permit - MECH.CONT. LIC.NO. MECH.
1; TOTAL _� TOTAL �O /737
'Sig at a ol'Apph ant/ tractor Date
OFFICE COPY