6192 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
a -
'BUILDING PROJECT IDENTI FICATION APPLICATION & PERMIT
PER M OI LNG• IT NUMBER
AD D
� BUILDING.-ELECTRICAL-PLUMBING-MECHANICAL 6192
O NE PLAN CHECK VALIDATION
NA O Y 'xr71 1 ELECTRIC PERMIT
�/IIO� Y Or✓'NGNE VV
c NTRn T EJN
94
Rs UTLETS-SWITCHES-RECEP 5.00/100
f LIC,Bo 1 ✓D, LIGHTING FIXTURES 56MT.00
P NTRACTOR'S '
• �( � RE Lf/ PPLIANCES-RESIDENTIAL 4.00 '
• { PNONE
-JW .PANELS S.00 DATE OF APPLICATION
I%RCHITECT SIGNS 6 PLAN CHECK FEE P.C.NO.
ENGINEER - '
LIC.No. SIGNS TRANS. 3.00 -
AARCH.OR DDRESS ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
• ZIP EMP.METER OR POLE INS. 15.00 ,
APPLI
ADDRESS
MOTORS SEE FEE SCH.
oREss �
. SERVICE CHANGE 10.00 - /v ass/1p
Oo LICENSED CONTRACTORS DECLARATION P r
ry w I hereby affirm,dod I am licensed under provisions of Chapter 9 - ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.r MECH.
r O i Professions Code my license is in full fur �f
o y1-1-9*
D License ss Lic.Number
F ,A F j Datc /- Contractor
ase -r C%t ;BUIL"DING PERMIT
a OWNER-BUILDF-R DECLARATION TION
e¢u,DV�INFORMA� �
w;LL y I hereby affirm that I am exempt from the Contractor's License MISC.,- REFER
u
04 - Law for(he following reason.(Sec.7031.5,Bashi...d Professions VALUATION .f a S/FT.
� - Cade:Any city or county which requires a permit to construct.alter, PERMIT ISSUANCE 6.00
u ELEC.CONTR. LIC.NO.
rc a.a improve,demolish, r repair any structure,prior to its issuance,also ELEC.
w0 LL, requires the applicant fat such permit to file a signed statement that TOTAL (�/ PERMIT TO
&m he is licensed Pursuant to the provisions of the Contractor's License
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 of the d "5,=-(f'i L
F 4 o Business and Professions Code)or that he is exempt therefrom and QTanY p`�.+w "PLUMBING PERMIT FEEv' �L'E 7i
I- the basis for the alleged exemption Any violation of Section 7031 5 "� .` STORIES TYPE CONSTR.
c3 � by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ [,ax owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 oec.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,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered lot IS.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 am.
Prove for purpose of sale.). . .00 RES IND CON PB Omer
INDUSTRIAL WASTE INTER20
❑ 1,as owner of the property,am 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
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200fr/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under See...BAP.C.for(his WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS-COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsen(to sell-ihsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compe u(IC o Insurance,rr a cern fed
copy thereof) e . R Lah.C.y// AA}/// rf
Policy No pony '�AI�C
❑ Certl led ereM1yuml. ed FIRE SPHINK ENERGY T-24
z Z O Cavi co filep� ith II y inspection division.
_I .. . ! MISC.- REFER TO ORD.
Applicant kp Y ❑ ry❑ y❑ N❑
~ �+ PERMIT ISSUANCE 6.00
Q CE '1'IFICATG OF H%F.M ONFROM WORKERS' PL000 ZONE A.LLLC.
111 > COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
(L O (This sectionneed not be completed if(he permit is for one N❑ Y❑
Z hundred d011ars(SID()orless.) - p -
TOTAL N
V O 1 certify that in the performance of the work for which this per. ' a'-` 64 `- *U 1p �L s - FEE SUMMpfRY
QTY. MECHANIC/1L PERMIITi $ 'a
Iy H_ mil is issued,1 shall not employ any person in any manner o as m e 4$
O w become subject to the Workers'Compensation Laws of California. =a. v
Date Applicant BUILDING
a ALTER OR ADD TO MECH. 4.00
} m NOTICE T'O APPLICANT: If,after making this Certificate sa Ex.
F Z cmvisionyou should become subject mean Workers'Ccomply lion APPLIANCE 4.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op000.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10p00GEM) 5.00 SEISMIC FEE
I hereby affirm that (here 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,Ch,.0-) , HEATING UNIT(TO 100,000'B.T.U.) 4.00
Lender's Name HEATING UN IT ER 100,000 B.T.U.)7.50 3 0-C
Lender's Address ELECTRIC
' . I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county- PLUMBING
ordinances and state lawsrelating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of (his city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag 'ast liabilities;judgme ts, costs and "POST which PERMIT ISSUANCE 3.00 CONST.TAX
may in any ay nccrue against d City i on qucnce of the
granlin of seer il. r H.CONT. LIC.NO. MECH.
TOTAL TOTAL'
ig tore (Applicant/Co m or to
OFFICECOPY '