4469 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIr NOMBEH
BUILDING APPLICATION & PERMIT
eDOREss r4469
- /, / BUILDING-ELECTRICAL--PLUMBING-MECHANICAL
OWNER'S ' PLAN CHECK VALIDATION
-�. NAME G _ OTY. ELECTRIC PERMIT FEE
SC a� PHONEL 3 -i:�•
CONTRACTOR'S
NAME ) I, OUTLETS-SWITCHES-RECEP 5.00/1.00
FClI�Yt �C G LIC.NO, )/tL LIGHTING FIXTURES 5.00/1.00
f,ONTRACTDRS 7 APPLIANCES-RESIDENTIAL 4.00
eOOREss
/Q L.i�/��•�C ��� PHoNE z.(2 �)y PANELS 5.00 DATE OF APPLICATION
OHCHITECT SIGNS B.00 PLAN CNECK FEE P.C.NO,
ENGINEER
Llc.No. SIGNS TRANS. 3.00
ARCH.
RCH Ess ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AIBADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o m i /TO
_09 LICfiNSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9 SUANCE DATE
w "' (commencing with Section 7000)of Division 3 of the Business and
Q y ECT. PLG. MECH.
D Professions Code ad gJau ase is in full force d jf t El ❑ ❑
License Class - Lic.Number L
m r Datc Com moor /O O
H w a OWNER-HUILDIiR DECLARATION
I F IN PERMIT
o a u INFORMATION
w ; H I hereby al firm that I um exempt from the Contr:mlors License MISC.- REFER TO ORD
.. O j Law for the following reason.(Sec.7031.5,Business and Professions 6.00 ty 0 1 no
$/FT,
r _ PERMIT ISSUANCE
Code:Any city or county which nquireso permit to construct,alter,
a ¢¢ � improve, or repairany structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELED.
DLL requires the applicant for such permit to file it signed statement that TOTAL
6 W mhe is liecuSed parsnaat to the provisions of the Contractor's License' _ PERMIT TO
FZQ
Law(Chapter 9(commencingwith Section 7000)a(Division 3 oflhe k&7kc,4,0
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M r $ the basis for the alleged exemption,Any violation of Section 7031.5 nSTORIES TYPX CONSTR.
d ; _ by any applicant for a permit subjects the al,licanl to a civil penalty ALTER-DRAIN& VENT-WATER IEA.14.00 ,"A,asd, hJ /NrSCu'
of not more than five hundred dollars(55001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 200
their sole compensation,will do the work,and the structure is not . OC¢.G�VP `ES.UNITS
intended ar offered for sol,(Set. 7044, Basins and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 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
0 himself or through his own employees,provided that such improve-
meats am not Intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or ire- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. RES IND CON PB Omu,
Cl 1,as owner of the property,am exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sea 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"nacos with a contractual)licensed pursuant m
the Contractor's license Law. SEWER-SANITARY-STORM EA, 200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under See. ,B.&P.C.lav this WATER HEATER W/VENT q,00
reason
Date Owner,• WATER SYSTEM 4.00 ACC.OATE ACD.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby ofrm that I have a certificate of comcat Ir sel Gimsure, ZONING ENG.SITE N0.
or u certificate of Workers'Colnpemsation 11,11.111e,or a certified - _
copy thereof(See.3800,Lab.C.). S./ �, �i 7
Policy No. Company i-
O Ver ified copy is hereby fumi0md, FIRE SPRINK ENERGY T 24
Z ^Z / 111�Certi udf copy_.I L4 illi ne fly inspection division.
Applicant MISC. ,REFER TO ORD. Y ❑ N❑ Y ❑ N❑
rn PERMIT ISSUANCE 6.00
jr CfSRTI PICCOM0 17 PENSATIION INS PROM N'OkKIiRS' FL000 ZONE A.L.u.c.
W > � COMPENSATION INSURANCE PLG:CONTR. LIC.NO. . PLG.
(This section need not be conmleled if th
e permit is for (tire TOTAL Y E] N❑ Y ❑ N
Z ❑
hundred dollars(S 100)or les")
V O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any p,raun in any manner sn as(I)
O W become subject to the Workers'Compensalion Laws of Cali o nia.
y Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} W NOTICE TO APPLICANT': If,after making this Certificate Of fix- T
H ? enghtnn,you should beconm subject to the Workers'Conhpcnsatiou APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most ba,thwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C F.M.) 3.00
CON$TRUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE S�
'I hereby affirm thal there 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NamAddy HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and nate that the above VENTILATION FAN (SINGLE) 3.00
rumination is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of,thi, city to cater upon the
above-mentioned property 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 against liabilities,judgments, costs and expenses which PERMIT ISSUANCE - 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting o([his ermi{. / MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature Of Applicant/Contractor Date ,
OFFICE COPY