8932 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION _ PERMIT NUMBER
BGILDINGopREss APPLICATION & PERMIT ^ G
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a
0 Cu / UILDING-'ELECTRICAL-PLUMBING-MECHANICAL y
OWNER'$ PLAN CHECK VALIDATION
rvamE OTY. . ELECTRIC PERMIT FEE
McL 2 PNDNE _
NOMrRacTDRs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00 4
f,ONTRaCTOR'S - '
IMapDREss APPLIANCES-RESIDEP D 4.00
1'I HONE PANELS.. 10.00 GATE OF APPLICATION
ARC
EN
SU
rSU�1.1y VA v PANELS (OVER 20 1, 19F, '20.00
PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS CH OR ENO' SPECIAL CIRCUIT City of CuDertiII05.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS - MOTORS FEE SCH.
ADDRESS
u 111 L, SERVICECHANG 2000. /'r`
ra S o LICENSED CONTRACTORS DECLARATION TEMP.POLE CC 30.00 / /
a v I hereby affirm that I am licensed under provisions of Chapter 9FRO
ISS NCE
y 4 eAi (commencing with Section 7000)of Division 3 of the Business and SLOG. EL CT. PLG. MECH.
H w Professions CoJ n my licenu is in full fore IOU ❑ E:]
❑
z O m- License Class Lic.Number 13 Q
. Z
H ° Dom. ,l-g. Contmctor.Z�� -
Q V 2 J R ,BUILDING PERMIT'
It a w a OWNER-BUILDER DECLARATION -
u INFORMATION
X ;a-y .I hereby affirm that I am exempt Gam the Contractor's License MISC.- . PREFER O O '
LO < Law for the following reason.(Sec.7031.5.Business and Professions VALUATION $/FT.
r - PERMIT ISSUANCE 10.00 p ^ 510 00
Cade:Any city or county which requires a permit to construct alter, M
0O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. ELEar
C. p/
YE T TO
O LL requires the applicant for such permit to file a signed statement that TOTAL tl
a w m a he is licensed pursuant to the provisions of lbe Contractor's License
rz >
Law(Chupmr9(commencing with Section 70001 of Division of the 41
Z z o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE '
m f $ the basisfor the alleged exemption,Any violation of Section703L5 STORIES TYPE CONSTR.
d3 � by any applicant for a permit subjects the applicant ma civil penally ALTER-DRAIN (EA.)of not more than five hundred dollars(8500).): -
❑ I,as owner of the property,or my employees wish wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do tire ru
e work,and the stcture is not
Mnded or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D:.5.00 '
e: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 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
"
mprove- -
mentsarenot intended oroffered forsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA) 2.00
builder will have the burden of proving that h - . - .
e did not build or im. BUILDING USE
prove for purpose of sale.). RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
❑ ❑ ❑ ❑
licensed contractors to constructeContract., project(Sec.,7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
to Professions Codeproperty
The Contractor's License Law does not apply
to tr owner of property who builds r improves thereon.and who LAWN SPRINKLERS;OVER 5(EA.) 1.00
contracts aru Licen e L with a comomorfsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. - PARCEL NO.
O ISTu exempt under Ser.-.B,&P.C.for this WATER HEATER W/VENT 6.00
raison
Owner.. Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No,
WORK 1iRS'COM PENSATION DECLARATION WATERTREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure
or a certificate of Workers'Compensation Insurance,or a ce rt lied ✓_U ZONING ENG.SITE NO.
copy thercof(Sce.3800,Lzb.C. G�.f 6 _ S
Policy No. GOnlpany _
0 Cl V FIRESPRINK ENERGY T-24
z Z li✓Cer'fe Copy 1•J 'it t�hc City insp-le-ctityyNl dyI']ision. MISC.- REFER TO ORD.
r�.+f APpicant�tJCG/-rC+ L-•M1� Y ❑ N❑ Y ❑ N❑
Cc rn / CE R1'I F11 ATE 01'H. EMPT1ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UX.
L COMPENSATION INSURANCE PLO.CON . PLG.
C Cl (this s"ectidn need not be completed if the-pennil is for one `I TR / TOTAL Y❑ IN Y E3N❑
Z hundred dollars IS 100)or less")
U O 1 certify that in the per(ormunce of the work for which this per, DTV. MECHANICAL PERMIT FEE 'FEE SUMMARY "
LL 1- mit is issued, 1 shall not employ any poison in any Turner,so as to
O w become subject to the Workers'Compensation Laws of California. '
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} y NOTICE TO APPLICANT: If,after making this Certificate of lix-
?
craft ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.FM.) 6.00 SEISMIC FEE
I hereby affirm Ihat Chore is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
rhe performance o1the work for which this permi Lis issued ISce. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50 3/ 69
Lender's NameAddress ELECTRIC
I Certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county - PLUMBING
•` ordinances and,state laws relating to building construction, and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Core 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mantioned property for inspection purposes.
(We) ugrce to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs an. expenses which - CONST.TAX
may in any way P rue against said City in consequence of the
PERMIT ISSUANCE 10.00
granting of thi,-p- nil. MECH.CONT. LIG NO. MECH.
I _ TOTAL TOTAL
Slgrlatureo Apptcant nTactor Date
OFFICE COPY