5846 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENT[FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS UILDING-ELECTRICAL-PLUMBING-MECHANICALlolfc � ir ' PWtlOp
OWNER'SPLAN CHECK VALIDATION
"nme 1
�S 3 (3 TY. ELECTRIC PERMIT FEE
L3qr
CONTRACTORS (
OUTLETS-SWITCHES-RECEP 5.00/1.00
_!'AMO�wCA, L Q
LIGHTING FIXTURES 5.00I7.00
CONTRACTOR
ADDRESS APPLIANCES-RESIDENTIAL 4.00
CZ -
E S 1 PANELS 5.00 GATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIc.No, SIGNS TRANS. 3.00
ADDDRESSS E"G' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS, 15.00
APPLICANT'S - MOTORS SEE FEE SCH. / �
ADDR Ess
SERVICE CHANGE 10.00 ��/6.
F o D LICENSED CONTRACTORS DECLARATION �J/p
WU 1 hereby affirm is at I am licensed under provisions of Chapter 9 ISSUAN E DATE
v, "' commencln with Section 7000)of Division of the li siI ss and'
¢ vdi ( 6 _I F BLDG. ELECT. PLG. MECH.
r N a I'ro(essions CO, un my license is in full fo ❑ ❑ ❑ ❑
Z O - License ChAriv`- Lie.Number
- Contractor
•
Q y J 10 BUILDING PERMIT
¢ w OWNER-BUILUIiR UECLARA ION INFORMATION
wo z. MI ER'TO ORD
;u w I hereby affirm that 1 am exempt from the Contractor's License VALUATION S/FT.
F LL O¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6,00
J Code:Any city orcounty which requiresa permit to construct,alter,
¢ rc Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. /
LL requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT TO
d w m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe AU �r Etr
¢ Business and Professions Code)or that he is exempt therefrom and, CITY. PLUMBING PERMIT F1
¢� $ thebasis for the alleged exemption.Any violation ofSection7031.$ TORIES TYPE CONSTR.
n ; � by any applicant for a permit subjects the applicant toacivil penally ALTER-DRAIN&VENT-WATER (EA.14. U e '
of not more than five hundred dollars(5500).): 0 A-✓ gAnG
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GR UP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended of offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 01 rr 'S� Cd
Code:The Conorclur'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 SD.FT.FLOOR AREA TOTAL ACREAGE
• ,himself or through his own employees,provided that such improve-
11 ments are not intended or Offered for sale.If,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 (EA.)
builder will have the burden of proving that he did not build or int- 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE INTER. RES IND CON PB ower
❑ 1,as owner of the property,um exclusively contracting with 20.00 El 0 ❑
licensed commetom to construct the project(Sec. 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 or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrac(ons)licensed pursuant to
the Contractor;License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,R&P.C.for this WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA1ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to sell-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation nsuran�i•.nr a certified
'7C copy thereof(Sec.3800,Lab.C.L('` 11"-� N.`
Policy No. Company_]
0 ❑ CcrtiF, it copy is h by furnished. FIRE SPRINK ENERGY LZ4
Z �, Certified copy fiteJ with the city inspection division.
MISC.- REFER TO ORD.
O Applicant - V IN E] V N�
♦- yCIiRTII°ICPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
A7 i OE fi%EMPTION FROM WO RS'
LU _ C PENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
Q"' O (This sectidn need not he completed if lite permit is for one TOTAL Y❑ IN V E3 NC]
0 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ ♦- mil is issued,I shall not employ any person in any manner an as to
U become subject to the Workers'Compenmtion Laws of California.
O w Date Apphcam BUILDING .�
a ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: 1(,subject
making this Certificate of Iix-
FZ movisio,you the Lbecome subject to Ise Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions io the Labor Cit shall
you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1OPM OEM.) 5.00 SEISMIC FEE s0
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(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cie.C.).
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application unit state that the above VENTILATION FAN (SINGLE) 3.00
iation is rorrect. I agree to comply with all city and county BOILER-COMPO H.P.or 100,000 B.T.U.) 4.00 PLUMBING
manres and Stale laws relaling to building construction, and
•by authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTUI SEE FEE SCH. MECHANICAL
a ova-menlio - roperty for i tion purposes.
(We) and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag'' St 1` ilities anis, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in y ay c rue i 'd City in consequence of lh
granting f s p n L MECH.CONT. LIC.NO. MECH.
_ f TOTAL TOTAL
Sign are ol'Applicant ractor Uate
OFFICECOPY