15011 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER -
" BUILDING APPLICATION & PERMIT O
ADpp E55
/ S/I- UILDING -ELECTRICAL-PLUMBING-MECHANICAL w.
1 1
DINNER ��!! PLAN CHECK VALIDATION
. Na54 • 996 3 TY. ELECTRIC PERMIT FEE
PHONE
CONT.ACTO 'S
NAME A OUTLETS-SWITCHES-RECEP 10.00/1.00 ,
(,(/• � G 'Llc.No.� Q / / LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
_. y/s
APPLIANCES-RESIDENTIAL 4.00 R&A1/(/ / &W -PHONE p2;zp -
PANELS - 10.00 DATE OF APPLICATION.
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 '
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR.POLE INS.
Aeeucarvrs - MOTORS - SEE FEE SCH.
SERVICE CHANGE 20.00
C o LICENSED CONTRACTORS DECLARATION
4�w 1 hereby affirm that I am licensed under provisions of Chapter 9 "'
rt n ISSUANCE GATE
lconrnemm�g with Section 7000)of Division 3 of rte Business tool BLDG. ELECT. PLG. MECH.
r y i Professions Coal5,a my license is in full force'
Z,i U o Licen / Lic.Number ./ _ I-LY
FNH J Dulc
Contractor
� I�
w -a. OWNER-BUILDER DECLARATION BUILDING PERMIT
° a`a MISC.- REFE O OR - INFORMATION
E:
0 r y I hereby a(finn❑oat am exempt from the Contracroi s License
m j Law for tireines
following reason.(Sec.7031.5,Buss and Professions PERMIT ISSUANCE VALUATION - $/FT.
m � Cade:Any city or county which requiresa permit toconslrucl,uller, -
improve,demolish,or repair any structure,prior to its issuance,also EC.C N R. ' LIQ NO. r�
2 ¢ O n TOL f
c LL requires the applicant for such permit to file a signed statement that lam _ O`�y/ TOTI lot,,:Y`
u w m he i,licensed pursuant to the provisions of the Contractors License "L ,J _ - PERMIT TO
HiQLaw(Chapter 9(cmnmencing with Section 7000)of Division 3 ofthe E(.�Z_•7-
E i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
an I- the husis far the alleged exemption.Any violation of Section 70315 STORIES TYPE CONSTR.
by any more
for ive permit subjectstire$500).licant toacivil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(EE00)J:
❑ I,as'owner of lire property,or my employees with wages as BACK FLOW PROTECT. DEVICE '4.00 OCC 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,CONO. 5.00
Code:The Contnmtor s License Law does not apply,to an owner of
properly who builds or improves thereon,and who does such work FIXTURES•PER TRAP 5.00• so.Fr.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,rhe huilding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6,00
or improvement is sold within one year of completion,ore owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or am- BUILDING USE
prove for purpose oursa1eJ' INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with . .
O
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'he nt
Coractor's License Law does not apply
to at
se
owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 c
comms for such projects with a contractor(,)licensed pursuant to
tSEWER-SANITARY-STORM EA.200ft
he Contractor's License Law. /10.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sea ,N.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM - 5.00 Ace.DATE ACC.FILE NO.
WORK ERS'COMPENSATION D17CLtRATION WATER TREATING EQUIP. 5,00 `
I hereby affirm that I have a certificate ofconsenr toself-insure,
or a certificate of Workers'Compensation Insurance,or x certified ZONING ENG.SITE NO.
copy Cher uI S-c,3800,Loh.C.L - -
Policy No I VM1I}�76mpany S�LQrr111-IetC
O ❑❑/l�erlil copy is he y I fished.
Z Z 0I le ICi S 1 d i the oily inspection division. FIRESPRINK 'ENERGVT-04
FO Applican�- - MISC. REFER TO ORD. v N v N�
CC y CEIg1'IFICATF.OF EXEMPTION FR WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPIiNSA'I'ION INSURANCE I� PLG.CONTR. LIC.NO. I.G.P
Z ('fhis section need not be completed if the Permit Win, one .;. TOTAL v N� v C] NE]
hundred dollma`(S 100)or less.)
) 0 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- m11 is issued,I shall not employ any person in any manner sn as no
Q L)become subject to the Workers'Compensation Laws of California.
y Dam Applicant BUILDING
�- w. NO'T'ICE'f0 APPLICANT: 11',alter making this Cerlificiiro of lix- ALTER OR ADD TO MECH. 5.00
F ? coalition,you should become subject to the Workers"COI>fpensution APPLIANCE 5.00 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 10=CF.M.) 4.00
CONSTRUCPION,LF,NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM '
3097,Cie.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
. 1 certify that I have read this application and slam that Ile above VENTILATION FAN IS I NGLEI 4.00
infor'm'ation is correct. I agree to comply with all city and county PLUMBING
mdinmmes and slate laws totaling In building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
'(We) agree to save, indenmil'y and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costs anJ expenses which CONST.TAX
may in any way accrue against said City in consequence of the PER ISSUANCE 10.00
printing of this permit. MECH.CONT. LIC.N0. MECH.
TOTAL TOTAL
Signature ol'Applicanr/Contractor Dare
' OFFICE COPY `