7124 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION -PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AOORESS
4 .iJ1.1 • I/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12
Ow Fn's Y�IU J1! PLAN CHE)5VALIDATION
N" E QTY. ELECTRIC PERMIT FEE - ID
PHONE
couTnncron's NAME UTLETS-SWITCHES-RECEP 5.00/1,00 f�AAl /�9
S,
LIC.No. LIGHTING FIXTURES 5.00/1.00 1985
CONTRACTORaPPLIANCES-R1.,(LESIDENTIAL 4.00 city Of
ADDRESS P r�
/ys�-' PnONFl` Z PANELS 5.00 DATE OF APP�ICe 017
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER O
LIc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 6,00 PERMIT VALIDATION
ADDRESS
zlv ITEMP.METER OR POLE INS. 15.00
AvvuCANTs IMOTORS SEE FEE SCH.
ADDRESS III
SERVICE CHANGE 10.00
oaz
Foo
LICENSED CONTRACTORS UECLARA'NON
a u v I hcrehy affirm Ihml I am licensed under provisions of'Chapter 9 ISSUANCE DATE
w a N (c mmencing with Seelion 7000)of Division 3 of the Business and BLDG. ELECT. P MECH.
F w z ufeuiun Code,am�PIy cense is in full force nJ efl'ea'.L
i
0.- icensc Cla s_�r=,j Lic.Number, 'ZT ❑ ❑ ❑
Q m o Uatc1= = Contractor
sa OWNI'R-RUILDER DECLARATION BUILDING EIOW ,4,;
w INFORMATION:
U REFER TO ORD
E:
ler I hcrehy altion Ilial 1 am cxcmpl Dom the CnnlraCl I's License MISG.- VALUATION
H .. o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE
3 w>E Code:Any city or county which requires a permit to construct.alter, ELEC.CONTR. LIQ NO.
Ie or Q O improve,demolish,of repair any structure,prior to its issuance,also ELEC
aru w
-O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(asmmencing with Section 7000)of Division 3 fthe
a Business and Professions Code)or star he isexempt therefrom and DTV. PLUMBING PERMIT FEE
D the basis I'nrthr alleged exemption.Any violation of Seelion 703 L5 STORIES TYPE CONSTR.
.w by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500)J:
❑ 1,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 not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code The Contractor's License Law docs not apply to an owner of
properly who builds or improve,Ticrcon,and who docs Such well FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
means a through his own employees,provided Ilial such improve-
means employees,ffered for provided
e. ed that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
he der will have the burden of proving that to did not build or im- RES IND CON PB Omar
prove for purpose ol'mle.l. INOUSTRIALWASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: file Contractors License Law docs 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 contract.00 licensed pursuant to
the Contacti's License Law. ' SEWER-SANITARY-STORM EA.200f t/8.00 TRACT No. PARCEL N0.
r
❑ Allo coxcmpl under See_,B.&P.0 for Itis WATER HEATER W/VENT 4.00
reason
Owner - Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMI'ENSA IION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of conical to self-insure, ___Z0N I NNG ENG.SITE NO.
mUil'ica c of Workers'Compensation In..ranee,or a certified
copy thearof(Sce IH U?L'ab. 1. z3� SS
Policy No. I y "' O (-
O! ❑ Cenitied cop ufnishcd. t -i � J PRESPRINK ENERGY T-24
Z Z ❑ CcUi ed copy is f d w' the city Snspcction division. MISG.- REFER TO ORD. Y ❑ IN❑ Y ❑ NF]nppl c:
F" y PERMIT'ISSUANCE 6.00 vL000 ZONE A.L.u.c.
LU - CERTIFICATE PE EXEMPTION FROM WORKERS'
W CO
> COMPIiNSA1'ION INSURANCE vLG.corvTR. LIC.rv0. PLG.
0 ('Phis section need of be completed if the permit is for one TOTA Y❑ N❑ Y ❑ N
0 2 hundred dollzrs(S 100)or leu.)
U 0 1 eertily that in the performance of lire work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY:
LL F mit is issued,I shall not employ any person in any manner so as to
Q0 become subject to the Workers'Compensation Laws of California. BUILDING
Go Date Applicant ALTER OR ADD TO MECH. 4.00
�- 0- NO'flCl:'TO APPI.ICAN7: If,after making this CeUificalc of Cx-
F 2 emption,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 10000C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm (hal there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the Pcdbrmauce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
immolation is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
I. ordinances and stale laws relating to building construction, and Y
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 1130L000BTUISEE FEESCH. MECHANICAL
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
gra ling 11 this pe....I JUCH.CONT. LIC.NO. MECH.
Item PS5,1 TOTAL TOTAL W.00
V Signat oreof Applicant/Contrzco Date
/\ OFFICE COPY