1118 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONLY
BUI LDI NG PROJECT I DENT]FICATION P RMI DER
9UIAD
LOING APPLICATION & PERMIT
�7� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ills
u
Y 118
J TCL/ 4 PSSOa
OWNER'S I Rtr IY 'a�l Ps! '{ h:- t PLAN CHECK VALIDATION
NAME N •fY-6-zf� OTV 5 `w x . ELECTRIC PEHMIT4j 4. l� '{4 FEEv.
#'�RT.A.T.
u�Ar?DN?3YaRS UTLETS-SWITCHESRECEP 50017.00
ME
SQ0 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR APPLIANCES 4.00
ADDRESS -RESIDENTIAL
'3Ltj PHONE '2LS(yr( I
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE I P.C.NO.
OR
E RE R LE , SCI sec.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. LQ 7 ALS S SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS /
141 -3 Ss Sae ala- AJ1 x,P9�Ot Z EMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. /
/O Sof- � PEC f SERVICE CHA 10.00 /0*
0 0 LICENSED CONTRACTORS DECLARATION
a U w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLOC. LECT, PLG. MECH.
iProfessions Code,and my license is in full force and effect. ❑ ❑ ❑
0i�-o License Class Lic.Number
Date Contractor �ga�/g ar�
m a a OWNER-BUILDER DECLARATION r1.rL =:^::�BUILDING PERMIT,
p a. r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 u P VALUATION S/FT.
M0, law for the fo0owing reason.ISec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Num Code:Any cityorcounty which requires a permit to construct.alter,
R<C improve,demolish.Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
Ii:p, requires the applicant fa..Lich permit to file o signed statement that TOTAL PERMIITYPECONSTR.x$ he is licensed pursuant to the provisions of the Contractor's License 3: •,_
_ii Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the s".i- s°1:re:`x -.r;*' ia + ISI
a Business and Professions Code)or that he is exempt therefrom and OTY �'fv V I PLUMBING PERMIT ti s ., yFEE ' /R/�
e $ the basis for the alleged exemption.Any violation of Section 7031.5 1:1`T :tr__v„gd)�fiS 1p'�w'yW>n fat.€ yLYt" 'f?{r; at SrDRIES
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00r
of not more than five hundred dollars(SS00).): 60
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Structure is not 3 ,
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractors 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. GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
ments arc not intended or offered for sale.If,however,the building
or"improvement is sold within one year of completion,the owner-D GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 LOING USE
proveer will have the burden of proving that he did not build or im- RES NO CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
RI,as..net of the property,em exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPO INKLERS-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 contractor/SO licensed pursuant to
the Contractor's License Law. 7ea1•�I SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
ClI am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date a WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of WOrkerl Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y C3 ❑ Y❑ N❑
I" Sn PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
j CERTIFICATE.PE EXEMPTION FROM WORK WORKERS'
W COMPENSATION INSURANCE. PLG.CONTR. LIC.N0. PLG. Y❑ N❑ Y❑ N❑
CL Z (This section need not be completed if the permit is for one TOTAL
hundred dollars(S I OO)or less.)
U O 1 certify that in the performance of the work for which this per- OTM ,: - '.R:,MECHANICAL PERMIT. ems :,FEE ,, `"'FEE SUMMARV�7
UL 5mit is issued,1 shall not employ any person in any manner en as in �� -
U become subject to the Workers'Compensation Laws of Caliannia. +� - L/
a Date Applicant ALTER OR ADD TO MECH. 4.00BUILDING •Sr0 a�O
>_ W NOTICE TO APPLICANT: IE after making this Certificate of Ex
I- Z emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AODC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 140WQEM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance or
of the wk for hich this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name /1j HEATING UNITIOVER 100,000B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct o
1 agree to comply with all city and county -PLUMBING
ordinances and state laws relating r to building construction, and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 4.00
hereby authorize representatives ins inspection
This city' to enter upon the BOILER-COMP 10",IOO,000STUISEE 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of IhiaS permit.QGy, '' I?, q MECH.CONT. UC.NO. MECH.&4. iS 9rJt TOTAL ••�' '-TOTAL •: V
Signature of ApplicanllConvaclor Data
OFFICE COPY