6771 ..APPLICANT,TO FILL IN INFORMATION WITHINRED'LINES.-'USE'BALL POINT PEN-ONLY
BUID G PROJECT I DENTI ICATION - PERMIT NUMBER
pL,La„N, �, APPLICATION & PERMIT"
.,,.. nhD as BUILDING - ELECTRICAL-PLUMBING-MECHANICAL I 6771
1
o.4D "
OWNER'S t1 /�s n - PLAN CHECK VALIDATION
I�SI//AA11C • I 1 CITY. ELECTRIC PERMIT FEE
LL TVI IY,1 N1�A\ HONE
NAMEnncTOns - OUTLETS-SWITCHES-RECEP "5.00/1.00
4 .Clea LIGHTING FIXTURES 5.00/1.00
no"eess TO $ y/2 rqL i 4 /ryqVkPPLIANCES-RESIDENTIAL 4.00
PANELS' 5.00 GATE OF APPLICATION
ARCHITECT - SIGNS 6,00 - PLAN CHECK FEE V.C.NO.
tt ENGINEER . , LIC.NO. I SIGNS'TRANS. - 3.00
ARCH.OR ENG. . PERMIT VALIDATION
+ ADDRESS , ' - SPECIAL CIRCUIT, '5.00 _
zIP EMP.METER OR POLE INS. "15.00
r� APPLICANTS • -
Aommss .. n MOTORS SEE FEE SCH.
1 - E .SERVICE CHANGE - 10.00 V /
Naw 00 LICENSED CONT RA(-TORS ULCLARA110N' ,( /(/�
a o u I hereby affirm (hal I am licensed under provisions of Chapter 9
way: (commencing with Section 7000)of Division 3 of Thu Busine s anti - ISSUANCE GATE
BLDG'. "ELECT. PLG. MECH.
r w z Professions Coda y cense is in full f I
z o - I,jet.. las Lic:Numb - - - '❑..
9 m r w Dame• Coolmtlor.2 y .
~ BUILDING PERMIT.
Q w u ^• OWNER-BUILDER DECLARATION- N�'' - .INFORMATION� "
w ;LL y' mreby affirm Oat I am eximpt from the Conlracior's cense - MISC:- REFER TO ORD -
ea .. OW Law r the following reason. 7031.5,Business and P essions PERMIT ISSUANCE 6 VALUnnDN_ SIFT.
Code: y city or county which requires a permit to con, ucLalter, _
IT Q¢Q improve, •mulish,re repair any structure,prior to its nuance,also ELEC.CONTE. LIC.NO. - " ELEC. `
A-wO a, requires Ih Plicant for such permit m file a Signe latemeni that TOTAL
m LL he is license Imo a ll In the provisions of the Co Actor's License PENT TOA /
FiQ l.aw(Chapter9 otdmencingwilh Seclion70 f Division 3 offle t '- L(7 d"-V '
4 0. Business and Pro ions Code)or that "C is craft therefrom and ATV. PLUMBING PERMIT' FEE
st F m , the basis for Ilse aIle -d exemplion.Any vi tion o"Section 703 L$ -: - STORIES TYPE CONSTR.
u by any applicant for a rmit subjects Bl pplicant loa civil penalty ALTER-DRAIN&VENT-
of nWATER (EA.) 4.00
'
ut more than five hu red dollars( 00).):
❑ I,Its owner of the p perry,u my employees with wages as
BACK FLOW PROTECT -2.00 OCC.GROUP RES.UNITS
their sole compensation,wil n 1 work,and the structure is not .DEVICE
intended oroffered for sale . 7044, Businiess and Professions pRAINS-FLOOR,ROOF,AREA,COND.' 4.00 '
Code:1 h Contractor's LR-co w does not apply to an owner of
property who builds or imp ve,t men,and who titles such work FIXTURES-PER TRAP '4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his ow employee provided that such improve. .
'mems are not intended LffcreL for s: •.If,however;tlIC h,ildinp GAS-EA.SVSTEM-11 4.00
Lr improvemaR is ud within one,year completion,the owner-
builder .will have th uNCR of proving aha e'did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) '1.00 BUILDING USE
prove for purpose f sale.).: x" , ' . RES "IND CON PB Other
❑ I,as own of the properly,am exclusive 'contracting will;
INDUSTRIAL WASTE INTER. 20.00
licensed cant ctors 10 construct the project(Se 7044,Business - LAWN SPRINKLERS- ZINC 5 V.B. 5.00 ASSESSORS PARCEL NO,
nd Profess' ns Code:The Contractor's License Law ICs or apply -
tL an Lw r of property who builds or improves then ,anti win • LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
conn. for such projects with a contnetons)licensed p .Lana In
the.0 ntmelor License Law. r SEWER-SANITARY-STORM EA.200ft/8.007RACT NO. PARCEL NO.
I soon am c�empf under Sec.-,B.&P.C.1 this WATER HEAT R NT ' 4.00 c
L
n W0Cr D°te WATER,SYST - 4.00 , ACC:DATE ACC.FILE-NO.
WORKF7RS'COMPENSATION DECLARATION: . WATER TUIP. 4.00
I hereby allorn that l lmve a certificate of consent to seliainsuc,
or a certificate of Workers J�CCyom��peerynn/spbion Insurance,or a c/e'r��lifiad ZONING ENG.SITE NO.
'coPY 111 I' f yr,3 Cit'jti�a-L< Y= ' . r-policy N N ff �.�.
❑ C-Ii led co py is hereby ourshed. - - FIRE SPRINK ENERGYT-24
Z 2ftino
" Certdl• p I file Y/Itl She city nspe'lion.Litt ran.' F
Rant •-+.1� T�1 t{ MISC.- _ r.. REFERTOORD.
-F O P 'rz�vl��F--. Y❑v.,N❑ Y O N❑
�
PERMIT ISSUANCE 6.00 -•y FLOOD ZONE. .A.L.U.C.rn 'ICA'I'li OP Ii XfiMl'TION FROM WORKERS" IW
�
W > PI:NSA'I'ION INSURANCE PLD.C0NTR. LIC.NO. PLG.
Z This section need no Cmpleted if the I is for One - TO Y NE] y n NE]
hupdred dollars(S 100)or less.)'
U O I.Ecrlity that in the Performance o - Is for which Olis per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY a
LL F, mit is issued, I shall not emplo person in canner So as In
U become subject to the Wor 'unmmisation Lhws o " mia.
Date 'anl BUILDING
a ALTER OR ADD TO MECH. 4.00
} m NO'IICE TO ANT: IL after making this Certificate of 17s.
F= empfou, ssodd become subject to the Workers'Compensation APPLIANCE' 4.00 - ` PLAN CHECK
prov s of the labor Code, you must hxthwifh comply with FEE
U I provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C•F.M.) 3.00 '
CONS'FRUClIONLENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 :SEISMIC FEE' y
I hereby affirm that there is a constnmtioi lending agency for EXHAUST HOOD(WITH,DUCT) 2.00 "
the performance of the work for which this permit is issued(Sec. -
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 'MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 '
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above - VENTILATION FAN,(SINGLE) 3.00 _
Inn onnutim, is carr Let. I agree to Comply with all city and county PLUMBING
oJnances and state laws relating to 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.(Ovar 100,000 BTU)SEE FEE SCH. 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 PERMIT ISSUANCE 3100 CONST.TAX.
may intil way'accrue against said City in consequence of the
granting of this penniL MECH.CONT. LIC.NO.' MECH. '
TOTAL TOTAL.
Signature of A pplicanOLD ntractor Date -
;OFFICE COPY " '