4295 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
IUILOING - APPLICATION & PERMIT ^
A OGRESS 495
G
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME
'Jet ! f f TV. ELECTRIC PERMIT FEE
II _
PHONE •
NAM,ACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
s 1 uc.No / LIGHTING FIXTURES 5.00/1.00
...T FACT 'S - S- APPLIANCES-RESIDENTIAL 4.00
AooREas
y P H 0 N PANELS 5.00 DATE OF APPLICATION
ARCHITE SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEEn '
_ LIC.No. SIGNS TRANS. 3.00
moo'Ess ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION '
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
ADoasss - /
' SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION /
4 Z W I hereby afllnn Ih of I am licensed under Proel s'ions of Chapter 9 ISSUANCE DATE
rn a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F H i Professions Cade,o A 'cense iv in full fore tial ❑ ❑ ❑ ❑
Z as w - License ass Lic.Number ,
o -O Datc Contrvclor
a y F J - LDING PERMIT
¢ ¢ a OWNF:R-BUILI]F.R DECLA RATIO
o s u INFORMATION
E
; H I hereby affirm that Lam exempt from the Contractor's s License MISC.- REFER TO ORD
Euo¢
Law for the following ruuson.lSec.703L5,Ousinessand Professions PERMIT ISSUANCE 6.00 U�� S/FT-
y,0 -' Code:Any city orcounty which requiresa permit toconstTuct,alter.
SE ¢ ¢ p improve,demolish,Or repair any structure,prior In it3 issuance,also ELEC.CONTR. LIC.NO. ELEC. Cl!
C, requires the applicant for such permit to file a signed statement that TOTALupemneIT TO
a
X$ he is licensed pursuant to the provisions of the Contractor's License C
F Z a Law(Chapter 9(commencing with Section 7000hrf Dlvision3of the CI C�Ur .� •
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE r
at I- o the basis for the alleged exemption.Any violation of Section 7031.$' STORIES TYPE CONSTR.
m by any applicant for a permit subjects the applicant to a civil penalty
of not Dino,than five hundred dollars(S5001.). ALTER-DRAIN&VENT-WATER (EA.) 4.00 S�?/ N6-/l�S
O 'I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00
their sole compensation,will do the work,and the structure is not OCC.GRO^P RES.UNITS
intended or offend for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00 C ��
Code
The Contractor's License Low does all apply to ua owner of
zm
property who builds Or Improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself n of Intel his awn,mployor Sale.If,edJhat such impmvo .
ments Impro meintendld withinrone yearol completion t thbowneg GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one your oft he
didlio t the owner- GAS-EA.SY,STEM'-OVER 4(EA.) 1.00 BUILDING USE
builder will have lite burden of proving that he Aid not build or inn- ,
prove for purpose of TicJ. l INDUSTRIAL WASTE INTER. 20.00 0 IND 0 ' PB 0
❑ L as owner of the property,ane exclusively contracting Ing with SP - .
licensed colons Cors to construe the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO...
toProfessions Code: ty Contractor's o improo s th does not apply
to frowner pfpropertywho builds rimproves thereon.and who LAWN SPRINKLERS-OV ER 5(Eq.) 7.00
contracts elm-'sor h cense L with a mntructrnfs)licensed pursuant In SEWER-SANITARY-STORM EA.200ft/8.00
the Contractors License Law. TRACT NO. PARCEL NO.
Per❑ I:un exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 4.00
Son
Date - Owner 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 NO.
or a certificate of Workers'CompoIl 1p/I Lxwrun RS u certifieA
copy thereof ISea.3800,Lab.C.l.{ 7 Y�7T'�y D
Polley Ne. Company
O q CvDiflcdcopy is hereby furnlshC FIRE SPRINK ENERGY T-24
Z Z �4 Certif eP ofyr fit dpi thr the city inspection division.
O Annllcam /�+�fP� ACt-/..0 MISC.- REFER TO ORD. Y N Y,� N�
1- rn TPERMIT ISSUANCE 6.00
CC (11;R II FIC'ATE OF EXEM PTION FROM WOR K E RS' FLOOD ZONE A.L.U.C.
LU - COMPENSATION INSURANCE. PLO,CONTR. LIC.NO. PLG.
0. a (this section need not be completed if the permit is for one TOTAL Y 0 NC3 Y❑ N
O Z hundred dollars C$100)or less.) '
U O 1 certify that in the p,dormance of the work for which this pe, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any mannerso as to
U become subject to the Workers'Connpensat inn Laws of Cdifornia.
O OL Date, Applicant BUILDING
} In NOTICE TO APPLICANT: If,after making this Certificate of ex- ALTER OR ADD TO MECH. 4.00
Z emplion,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 Ihis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 'SEISMIC FEE
I hereby affirm that there is a construction Iemhag'agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of tire work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T,U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
in,...nation is ,..went. I agree ,,comply with all city and County PLUMBING
ordinances and state laws relining to building construction, and BOILER aC.OMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorirc representatives of this city to enter upon the BOILER-COMP lose,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection puopoecs-
(We) agree to save, inAm
, nify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may.in.any way accrue against said City in Conserlumnce of the
gmoting of Ihis pent' MECH.CONT. LIC.NO. MECH.
6_ TOTAL TOTAL yv
Signature of leant/ o actor Dale '
OFFICE COPY