5612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
.GILDING APPLICATION & PERMIT
ADDRESS 5612O1 d M /f BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5i4ra dh PLAN CHECK VALIDATION
NAME OPV^: ` '""'-ELECTRIC PERMIT'd`-ai-'' I f BFEH"
PHON
. 7�OCEry/CSG' / - "*.
E
CONTRACTORS
NAM
- dZOUTLETS-SWITCHES-RECEP 5.00/1.00
11U67 (- ez"' re"C C.No.1733 f� LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'SPPLIANCES=RESIDENTIAL 4.00
AODR ESS
VO (� s�cJt) /118: PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE .C.NO.
OR
ENGINEER
, sec.No. SIGNS TRANS. 3.00
ARCH.OR ENG SPECIAL CIRCUIT 5.00 D PERMIT VALIDATION
SS
aP EMP.METER OR POLE INS. 15.00
ADDRVSnrs MOTORS SEE FEE SCH.
APPLICA
SERVICE CHAN E 10.00
Woo LICENSED CONTRACTORS DECLARATION
u U 1 hemhy affirm Ilial I am licensed under provisions of Chapter 9 ISSUANCE DATE
Na (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECH.
r w z Professions Calc,unA my license is in full farce u •ff ct ❑ ❑ ❑ ❑
i 0,,,- Liccnsc D ashy(per,//���(��Lic.NAmbcr
OR
r w Datc___�7' / .Contractor
ams -+ BUILDING PERMIT,;
¢ ¢ ¢ OWNIiR-BUILDER DECLARATION '
o.u INFORMATION'.
N. ;,_N I hereby affirm that I am exempt from the Contractor's License M ISC.- RTO ORD
VALUATION
ru0J Law for the following mason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
,A m Code:Any city or courtly which requires permit to construct,alter,
QQ ¢ n improve,demolish,or repair any structure,prior In ilsissuance,also ELEC.CONTE. LIC.NO. ELEC. ,i
n wO LL requires the applicant for such permit to file a signed statement[hal TOTAL 01,i PERMIT TO
$ Ile is licensed pursuant to the provisions of the Contractor's License
z¢ La.(Chapter 9(commencing with Section 7000)of Division 3 ofthe L r
4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IS the basis for the alleged exemption.Any violation ol'Seclion7031.5 STORIES TYPE CONSTR.
nim by any applicant for a permit subjects the applicant Ina civil Penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than Ove hundred dollars(1500).1:
❑ 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[he 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 50.FT.FLOOR AREA TOTAL ACREAGE
Ilio scif or through hisown cmployces,provided that such improve.
.cuts are not intended or offered far sale.It',however,the building GAS-EA:SYSTEM-I1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving mat he did not build or lm' RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20OD
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors I.construct the project ISec. 7044,Business LAWN SPRINKLERS-1 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.r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for such pmjeets with u contruetons)licensed pursuant to -
tile Cman,im"sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.tin this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.GATE ACC.FILE N0.
WORKERS'COMPENSATION DFCLARA'I'ION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO,
copy thereof(Sec.3800,Lab.C.L
Policy No. Company
U ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T@4
z'Z O Certified copy is filed with the city inspection division. MISC- REFER TO ORD. '
0 Applicant Y❑ IN❑ Y ❑ N❑
� w
CIiRT'I PICA'I'Ii OI:.IiXCh1PTION PROM WO It KIiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > ' - COMI'IiNSATION INSURANCE PLG.CONTE, 4C.NO. PLG,
Z 1'I'his section need not he completed if the pennil o for one TOTAL V❑ N❑ Y E] No
hundred dollars(5100)or IessJ
U O 1 certify Um1 in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
ELF mit is issued,I shall not employ any person in any man so as to
O Ed beco ec{�o the Workers'Cu nsalion Laws 0 fo ia.
y Dw Sf'A p'li°au[ ' ALTER OR ADD TO MECH. 4.00 - BUILDING
} to NOTIC T I' LICAN'1': IL Ing -
♦- ? empti.n,you should hecume.mhi to the ._kers' 1 16Ni1 tion APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must,forthwith comply vii tl FEE
U mch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C-F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm thin 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,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC 'V
I certify than I have read this application and state HIM the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3H.P.Or 100,000B.T.U.) 4.00
hereby authorize representatives oI' this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We),agree to save, indemnify and keep harmless lire City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs unit expenses which CONST.TAX
may in any way le o airs t said City in consequence of the v PERMIT ISSUANCE 3.00
grant' this pen / MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
ria re o pp oar or oto
OFFICE COPY