C 3392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BUPERMIT NUMBER -
t - ILDING.PROJECTlDENTIFICATION, APPLICATION & PERMIT '
AWL-"� C � 3392
SO ss
.0 BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
1 Got S - - - - - '-- - --- --_--- - _ - PLAN CHECK VALIDATION
"AMe l)PPHONE
- QTY. ELECTRIC PERMIT FEE
GN
E /$
NAAMERAcroRs UTLETS'-SWITCHES-RECEP 5.00/1.00
w/IL/I ZU4' LIGHTING FIXTURES 5.00/1.00
CCNTRACTORS - Al - - 'APPLIANCES-RESIDENTIAL 4.00
ADDRESS - j'
P•D.?CfI abC PRONE Y97-10 30. PANELS _ 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
,ENGINEER' L1. IC,NO. SIGNS TRANS.- 3.00
ADDRESS eNa. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
- ZIP rrEMP.METER OR POLE INS. 15.00 - -
APPLICANTS MOTORS SEE FEE SCH. ' ' 7
' ADDRESS -
.y,. SERVICE CHANGE 10.00 'I}�'/ p /
oo LICENSED CONTRACTORS DECLARAT ION '// � O'�
a v U I hereby affirm that I am licensed under provisions of Cliaptci 9 ISS///DANCE GATE
w (commencing with Section 70001 of Division 3 Of the Buainess and
¢ n a D ELECT., PLG. MECH-
r w i Professions C�1- ue is in lull I'orc'I�a 'Te� _- ❑ - ❑ ❑ r
o i m o License ^ 1-ic.Number'
N r
Date Cont mcmr_Y7/
I BUILDING PERMIT
re rc w - OWNER-BUILDER DECLARATION }
" o a. MISC.- REFER TO ORD i • INFORMATION
L 0 H 1 hereby affirm that I am exempt.from the Contractor's License
a LL o ¢ Law for the following reason.(Sec.7031.5,Basiliec and Pndessions PERMIT ISSUANCE 6.00
VALUATION - S/FT-
� us� � Code:Any city or County whichrequimsapermitloconstn¢t,alteL ,/ Ori -
¢ ¢.O improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC.
at O u requires the applicant for such penmit'to file a signed statement that ', TOTAL (I,IiER MIT T
u w m m Ie is licensed pursuant to the provisions of the Contractor's License aid
E. z Law(Chapter?(commencing with Section 7000)of Divisi�n3nf the
5 1 a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE (` '
.Ic 0 the basis for the alleged exemption.Any violation of Section703L5 ;_' STORIES It s./� TVP CO OR.
g: by any applicant for a permit subjects the applicant loo civil penalty - gLTER-DRAIN & VENT-WATE1.
R (EA.) 4.00 ll
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE . �e
their sole compensation,will do the work,and the structure is not 2.00 'IJ V CCa ,�OP In REB.UNITS 1
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dins such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
- himself or through his own employees.Provided that such improve^ .
mems are not intended or Offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold 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-
provefor Purpose ofsale.-1. INDUSTRIAL WASTE INTER. RES IN Co Pa Ome,
❑ 1,as owner of the property,am exClusivCly contracting with 20'00 ❑ ❑
licensed contractors to construct ate praHer(Sec.7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSLSSU/5WHCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property win builds or improves thereon.and who LAWN SPRINKLERS
5(EA.) 1.00 _
contracts forsuch projects with o contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/B.00 .
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I um exempt under Sec. WATER HEATER W/VENT 4.00
reusov
Dam Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILEND.
WORKERS'COMIIiNSA'I'ION DECLARA'[ION WATER TREATING EQUIP. 4.00
I hereby affirm that I has OW'. titan
cute of consmn to self-insure,
or ce'lifieate of t�/a/Va ton Insurance,or n cert il'cd ZONING ENG.SITE N0. .
copy tic orp 6 ILn C� 1 .
Policy N Company_1r�'�''',,L .
O O Certified copy is hereby farnis,e' ,I FIRE BPRINK ENERGY T44'
Z Z !� Certified copy I, Filed with the uty inspeetion div�on, '
O Ann can
MISC.-. REFER TO ORD. Y ❑' N❑ Y Q. N[]
1-_y PERMIT ISSUANCE 6.00
LU - l'IiR'IIPICA'TE(IIs SATION ION FRONI WORKERS' FLooO2orvE A.L,u U.C.
W > COMPENSATION INS URANCI? I PLG.CONTE. - LIC.NO. PLG.
d O (This se,hou need nut he completed if the permil Is fm one' '+ - TOTAL Y❑ NE] Y❑ No
D Z huodreddollms(SIOO)or C..) -
U O'' I certify that in the performance of thework forwhich this pew QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL E- mit is issued,I Shall not employ any person in any manne so as to
.'O w become subject to the Workers''Compensation Laws of California.
St. Dmu Applicant ALTER OR ADD TO MECH. 4.00 - BUILDING S� ,
�-'Ca NOTICE TO APPLICANT: If,after making this Certificate of fix-
•F Z mnption.you should b Come son,,el to the Workers'Compensation APPLIANCE 4.00 PL N CHECK
provisions of the Labor Code, you must forthwith comply with '
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 101 3.00
. CONSTRUC'TION LENDING AGENCY AIR HANDLING UNIT(OVER 110MQEM.) 5.00 SEISMIC FEE -
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the ranee of the work for which this permit is issued(Sec. MICROFILM
Lnde7.Lender's
CO.Na 1. - HEATING UNIT(TO100,000 B.T.U.) 4.00
Leender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50
' 1-undds Address - ELECTRIC �
I certify that I have read this application and stale teal the above VENTILATION FAN (SINGLE) 3.00 -
information is correct. I agree to comply with all city anti county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
1 hereby authorize representatives of this city es enter upon the BOILEWCOMP IOver toL000 BTU)SEE FEE SCH. ' MECHANICAL
above hereby authorize
entioned property for inspection purposes to, -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,Judgn •its, costs and axpeoaes which PERMIT ISSUANCE 3.00 CONST.TAX
may*)( iisperinit.
ccrue agai t id City in conser cone f the
• g
tin, Ecu.CONT. LIG NO. MECHa,c �� OTALTOTAL
Ig aan Contr ctor' Date
OFFICE COPY - --_1