16070 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY.
BUILDING PROJECT IDENTIFICATION .PERMIT NUMBER
UILO1NG APPLICATION & PERMIT' r]O i
ADOREss {{�Y f
LD RVI QS BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNER' PLAN CHECK VAL IOATION
` NAME]'' k1 'R-0 1./ OTY. ,ELECTRIC PERMIT. FEE
P��tR,OVJKA MI..NE �✓�-7! / �T�
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00 ..
uc.No. LIGHTING FIXTURES 10.00/1.00 - T '
c rRAcroR' APPLIANCES-RESIDENTIAL `4,00 COti 2J`,
HCODE.
PHONE PANELS "- ' - 10.00 _ DATE OF APPLICATION
ARCHITECT -OR PANELS (OVER 200 AMP) - 20.00 PLA FEE "- o' -
ENGINEER, - -
uc.NO .. SIGNS TRANS, 3.00'
ARCH,OR ENG.- PERMIT„VA TION
ADDRESS - .SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLEANS. 20.00
APPLICANT'S f"
ADDRESS �A�r, ,tel t MOTORS SEE FEE SCH. Oe_�y/v7i�s',
pcf/pfTH *—�J SERVICE CHANGE 20.00. 1„
o.o LICENSED CON'IRACTORS DECLARATION - 1�f CO�BIrNII�
w l
M v�`,� I hereby affirm that I am licensed under provisions of Chapter9 V NCE DATE
'a' (commencing with Section 7000)of Division-3 of the Business and
D z Professions Code,and my license is in full force and effect. -
BLDG. ELECT. I PLG. MECH.
o o — License Class Liu.Number
C -
O a Dale Contractor El El
P: m _,
, -' - BUILDING PERMIT
M
¢ ¢ w OWNER-BUILDER DECLARATION - INFORMATION
K
; ' se I hereby affirm that I em exempt from the Convector's License MISC.— REFER TO ORD
u VALUATION
a o Law for ity owe reason-ch req iresa permit
to ciod Professions - $/FT.
� — g g PERMIT ISSUANCE - 10.00
Code:Any city or cou Ny which requiresa Vermitio conetmcL alteq Q �
¢ ¢¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. /
LIC.NO. ELEC. •l
o ¢ requires the applicant for such permit to file o signed statement that
i w m u TDTAL - PER MIT TO
he is licensed pursuant to the provisions of the Contractor's License _
ve Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a, Business and Professions Code)or that he is exenmt therefrom andDTV. PLUMBING PERMIT - - FEE (((•���--- -
¢ _ $ the basis for the alleged exemption.*Any violation of Section 703 E.5 STORIES TVPECONSTR. -
s. by any applicant for a permit subjects the applicant toreivilperalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom than five hundred dollars($500].1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE - 4.00 OCs:GROUP RES.UNITS
their sole compensation,will do the work,and the structure is riot -
intended or offered for sale (Sc,. 7044, Business and Professions - DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply m an owner of
property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided that such improve-
merits are not intended ughhis..a ffered for employees.....ided that ehe building GAS-EA:SVSTEM-1lINC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have One burden of proving that he did not build or an- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 - BUILDING USE
prove for purpose ofsale.). I - RES IND CON PB Other
❑ 1,as owner of the property,am exclusively'contracting with INDUSTRIAL WASTE INTER. • 30.00 - ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business - LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Low does not apply ,
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.)' 1.00 i
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. - PARCELPI
❑ l am ex f minds—'. '+ ,B.&P.C,Ho this ' WATER HEATER W/VENT 6.00
teason
owner L Date WATER SYSTEM' 5.00
� 'ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. - 5.00
I hereby affirm that I have a certificate of consent to"If-u sure, -
or a`ecrtificate of Workers'Compensation Insurance,oLa"certiNcd ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished. ' FIRE SPRINK ENERGY T-24.x'
Z Z ❑ Certified copy is filed .with the city inspection division.' _
p Applicant 1 MISC.- - REFER TO ORD. Y [:] N❑ YO N�
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00' . FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
d Cl (This wetidn need not be completed if the permit is for ane _ .TOTAL 1 1 YE] NE] Y 0 .'NC
D Z hundred dollar,IS 100)or less) - -
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner so as to
L) become subject to the Workers'Compensation Laws of California. -
y
Date Applicant ALTER OR ADD TO MECH. 5'.00 BUILDING 35L
( .�- SO NOTICE TO APPLICANT. If,after making this Certificate of Ex- t
FZ emption,you should become subject to the Workers.Compensation APPLIANCE' _ 5.00 PLAN CHECK visions of the Labor Code, you must forthwith comply with FEE
,
pro '
. C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER I0,000C.RM.) 6.00 SEISMIC FEE
I hereby effinn that.there is a construction lending agency for EXHAUST HOOD (WITH DUCT) .5.00 ,
the perfunrmoce'Of the work for which this permit is issued(Sec, MICROFILM
3097,Chi C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.) ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
- information is correct. Lto comply with ucity and county BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING '
ordinances and state laws, Visiting m ting building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SORE. 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 10.00 CONST.TAX
nay in an}' way a ue against said City in consequ, cc of the . . _
,ranting ni�per 1 G MECH.CONT. LIC.NO. TMECHOTAL �
(/ A lo' y V TOTAL TOTAL L/
(J V
,Cl
of Applicant/Contractor ate
OFFICE COPY