3890 APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES — USE BALI_ POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATION' - - PERM IT NUMBER
B.ILDING •APPLICATION & PERMIT Q(� 0
ADDesssft I U�J
BUILDING — ELECTRICAL—PLUMBING—MECHANIC k
CONCH'S - ., - P AN CHECK VALIDATION'
NAME - OTV
PHUrrE . ELECTRIC PERMIT FEE
a g�-��
CONTRACTOR'S
NAME j - OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC,No'3a 9:"4
LIGHTING FIXTURES 5.00/1.00 ,
AOIS CONTRACTORs APPLIANCES-RESIDENTIAL 4.00
ONE PANELS 5.00 DATE OF APPLICATION
ORCHIi C I SIGNS 6.00 PLAN CHECK FEE. P.C.NO.
' ENGINEER t �
no. SIGNS TRANS. 3.00
ARCHESR
0 ENG. - SPECIALCIRCUIT 5,00 PERMIT V LIDATION
ZIP TEMP.METER OR POLE INS. 15.00 ��
APPLICANT'S -
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE - - 10.00' 1
o ¢ i
F 0_0 LICENSED CONTRACTORS DECLARATION -
a u to 1 hereby affirm that I.am licensed under provisions of Chapter"
at 4 y (commencing with Section 7000)of Division 3 of the Businessland LD ELE E DPLG MECH.
Z Professions Co a y license is in full fore and flee: ,r.L
o i w C License Cl - - Lic.Numhe��
Dale Contractor,
¢ OW ER-BUILDER DECLARATION ' BUILDING PERMIT
CallaU MISC.'— REFER TO ORD INFORMATION -
;u �- Thereby affh hal I am exempt from the Contracmr',L� '
u0¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
Code:An cit a,count PERMIT ISSUANCE 6,00
Y Y Y it my structure,prmittomnsuanc alter,
rc ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,aISO CLEC.CONTE'. - LIC.NO. rr S1 v�O
ELEG. V
n
o u requires the applicant for such permit ns file a signed actor's i mss TOTAL
w m he Is licensed pursuant to the provision of the Contractor's License PERMIT TO
rzi Busi(Chapter9(commencingwith Section is7000)
exempt theam3ofthe
X ¢ o Business and tile
alleged Code)or that he is exempt thcrcfrom31.5 OTV. PLUMBING PERMIT- FEE
I[ I- pN the basis for[he alleged exemption.Any violation oCSec[ion.7031.5 - STORIES TYPE CONSTR.
'a ; � .by any,applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).): t ALTER-DRAIN& VENT-WATER (EA.) 4.00
t ❑ 1,as Owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 occ.GHOUP SA RES.uNlr
their sole compensation,will do the work,and the s riclure is not
intended or offered for sale (Sec. 7044,-Business'und Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4,00
Code:The Contractors License Law docs not apply to an owner of
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-
or improvement
not intended w thinoffered
on farsale.o IL however,thebuildingo GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 , BUILDING USE
builder will have the burden of proving that he did not build or im 5 IND CON PB Other
prove for purpose of tileJ. trapti . INDUSTRIAL WASTE INTER. 20.00 �-
❑ d as owner Of the property,em exclusively. 7044,Bc with -
licensed.contractors Code: I construct the project La does Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSOHS PARCEL NO.
El 1:1
and Professions proprty Contractor's License Law does not apply
to contracts
foofpropertywho builds Or Improvesthereon,pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 7.00
contracts for such projects with s contractor(s)licensed pursuant to
theContractor's License Law. - SEWER-SAN ITAR V-STORM EA.200ft/6.00 TRACT No. PARCEL No.
❑ lam exempt ander Sec.—,BAP C:for this
reason WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP- 4.00
1 hereby affirm that I have a certificate Of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. '
Copy thereof Sec.3800,Lah.CJ� -
Policy No. r ,b y
Z ❑ Certified copy is h •by furhislrnh -
FIRESPRINK ENERGY T�24
Z
Z Y ❑ CerC 'If copy is filed witl the hK.lnspectj n division. .
., P,p^ Applicant• - MISC.- REFER TO ORD. v � N❑ v � N�
M CERTIFICATE.OF EXEMPTION FRO ORKF,RS'Y` " -a iPERMIT ISSUANCE- - � 6.00 ' s. --- FLOOD zorvE A.L.u.c. .
W > COMPENSATION INSURA .. PLG.CONTE, u0.NO. PLG.
D' O (This section neednot be completed if the permit is for one TOTAL v N Y N
Z hundred dollars($100)or C") +
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE -FEE SUMMARY-
LL F- mit is issued,1 shall not employ any person in any manner so as m
O W; become subject to the Workers'Compensation Laws of Call form la.
Dmc Applicant - BUILDING
} N NOTICE. TO APPLICANT: If,after nuking this Certificate of Fx- ALTER OR ADD TO MECH. 4.00
F Z collation,you should become subject to the Workers'CompensationAPPLIANCE 4.00 PLAN CHECK
provisions Of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall d armal revoked.' - AIR HANDLING UNIT(TO 110=11F.M.) ' 3.00
CONSTRUCTION LENDING AGENCY " AIR HANDLING UNIT(OVER IO,000C.EM.15.00 SEISMIC FEE
I hereby affirm that there is o construction lending agency for EXHAUST HOOD (WITH DUCT) '2.00
the performance of the work for which this permit is issued(Sea • MICROFILMS
3097,Ci,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's e
a
Nm - HEATI NO UN IT ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Name "
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Information n correct. 1 agree to comply with all city and countycribBOILER-COMP(3 H,P,oT 100,000 B.T.U.) 4.00 PLUMBING
hereby ccs and state laws roves of
building cohief ion, and
horsey chose-mentioned
representatives moves of this city to anter upon the BOILER-COMP IOvur 100,000 BTU)SEE FEE SCH. MECHANICAL
ahove-mentinned property for inspection purposes.
(We) agree toTsave, indemnify ono keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and,exhenses which PERMIT ISSUANCE 3.00 'CONST.TAX
may in any way accrue agains s id City in consequence of the
granting of this pefmil. MECH.CONT. LIC.NO. - MECH.
TorgL TOTAL
Sign ore of p ma /Cont star Du l
- OFFICE COPY -