5871 ICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
"HONG APPLICATION & PERMIT
.11ss
P a � 5 8 71
Oo103 wu-a.ls�. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
GINNER'$ �, PLAN CHECK VALIDATION
L'-E
"a E !� r� OTCVv!4% - "s"ECTRIC'PERMIT z :'pJ v+ FEEtf
I AINar�
NAME c*ons UTLETS-SWITCHES
-RECEP 500/100 r
CONE
LIC.NO. LIGHTING FIXTURES - 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADOR ESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
On
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCHEOR E.G, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS TORS SEE FEE SCH.
SERVICE CHANGE 10.00
oro o LICFNSED CON'TRACI'ORS DECLARATION
a v w I hereby affirm that I am licensed under provisions o1Chapter 9 ISSUANCE D E
w<a (commencingwith Section 7000)of Division 3 of the Businessxnd - BLDG. ELECT. PLG. MECH.
H N z 14nfessions Code,and my license is in full force and effect -�- F1 El
z o m License Class Lic.Number Ni I
O Z H s Uatc - Cnnlfactur `-
. ':BUIL""DINGkPERN
¢ >: ¢ ¢ OWNER-BUILDER DECLARATION is-•
M ¢di u `+INFORMATION
IT
0 T I hereby affirm that I am cxem t from the Contractor's License MISC.- REFER TO ORD "
w S u H ya p VALUATION $/FT.
F ..o ¢ Law I'or the following reason.(Sec.7031.5,Busioessmsd IToficlslm's PERMIT ISSUANCE 6.00
o Code:Any city or county whichrequiresa permit to construct.alter.
QQ Q Improve,dernolish,Or repair any structure,prior to Its RsuanR,aIW ELEC.CONTE. LIC.NO. ELEC.
- O
IT requires the applicant for such permit to file a signed statement Ihnt TOTAL PERM T TO
n w m" he is licensed pursuant to the provisions of the Contractor's License
H z r
Law(Chapter 9(commencing with Sce(ion 7000)of0ivision 3 ofthe -
4 o lbenness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE�� tA
TE I-o the basis far the alleged exemption.Any violation of Section 7031.5 STORIES VPE CONSTR.
d � , by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN -WATER (EA.) 4.00
.fool marc than five hundmd dollars($5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure is nut
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA COND. 4.00
q Code:The Contractor's License Law does not apply to an owner of
11 property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
�� himself re through his own employees,provided that such improve-
meats o net hroug his oncru to fors alclf,howeat such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
A2 (.y or improvement is sold within one year or completion,the owner. -EA.SYSTEM-OVER 4 (EA.) 1.00
builder will have the burden of proving that he did not build or im- GAS Es IND BUILDING USEPB Omar
CON
prove for purpose of sale.). , INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of clic property,dill exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors 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
c ttmets lir such projects withacommetoHsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
hs Contractors License Law.
I din •mmpt under Scc. ,B.&P.C.for phi WATER HEATER W/VENT 4.00
res n
Owner �L ^� WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I ION nl: ARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,bra L sfifreil
copy thereof(Sec 3900,LAC.).
Policy No. Company
O- ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z' ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant' ' V ❑ .N❑ V [:] N❑
I y CER'I'IFICA'I'ti OF Ii XFMPI ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
Lu CON COhIPI?NSATION INSURANCIi PLG.cOrvTR. LIC.No. PLc.
V❑ N
d ❑ (Phis section need nut be completed if the permit is for ooil TOTAL ❑ v❑ N❑
Z) Z hundmd dollars C6 1000or loss.)
U O 1 certify unit in Ihu performance of tiro work for which tper QTY. MECHANICAL PERMIT FEE FEE SUMMARY .
LL-LL- H mil is issued,I shall not employ any person ihis n any manner so as to
O w become subject to the Workers'Compensation Laws of California.
Oatc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
>- 'W NOI'ICI.TO APPLICANT: If,after making this Certificate of Es-
F, Z arlption,you should bucolrlc'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 10=C F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,DODGEM.) 5.00 SEISMIC FEE
1 hereby affinti 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. MICROFILM
3097,Co C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC -
I Lcndcr's Address
� 1 bcertify that l have,cud thisuppliciami and state that the above VENTILATION FAN (SINGLE) 3.00
i� in1 tTration is correct. 1 agree to comply with all city and county PLUMBING
m
ordinances and state laws relating building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over100,000BTU)SEEFEESCH. MECHANICAL
�'v1.11Y' above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gran fngo(this ermit. MECH.CONT. LIC.NO. MECH.
a Q' TOTAL TOTAL
ignature ofA /Contractor Dat
is OFFICE COPY
s