5938y(7P12NICANT TO FILL IN.INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLYBUILDiNG
PERMIT NUMBER.'
BUILDING PROJECTlDENTIFICATION APPLICATION SL PERMIT
ADDRESS BUILDING — ELECTRICAL —.PLUMBING -
OFFICECOPY r
MECHANICAL
5938
PLAN CHECK VALIDATION
•
OTY. ELECTRIC PERMIT FEE
E
'
CONTRACTOR S .�O a�3
NAME
OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES •, 5.00/1.00
um. NO.'
"
OF APPLICATION
CONTRACTORS
ADDRESS C �I
—. PHONE / —ry
PPLIANCES- RESIDENTIAL 4.00
PANELS- ' 5.00DATE
'
ARCHITECT V
OR .
ENGINEER •
- LIC. No.
SIGNS . 6.00
?LAN CHECK FEE P.C. NO.
,.
SIGNS TRANS. 3.00
ARCH. ss. ENG , , _,.
- ZIP
- SPECIAL CIRCUIT. '5,00
PERMIT VALIDATION
r
i
'
rSi
TEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRE 5'
G
MOTORS SEE FEE SCH,
SERVICE CHANGE i 10.00
` LICENSED CON 'IRACTORSDECLARAIION;,
-
I hereby affirm that I an licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code-- icensc is in full rcgil r r3
Liven l—ass Lic. Numberr 'p�(
Date Contractor_
v ISSUANCE GATE
-
BLDG. ELECT,
ElI❑j•
PLG. MECH.
,
..
•" . OWNER -BUILDER DECLARAI ION
I hereby affirm that 1 am exempt from the Contractor's License
Law for (he following reason. (Sm. 7031 5, Business and recessions
Code: Any city or county which requires a permit to construct, alto.
improve, demolish, or repair any stmclure, prior to its issuance, also
requi s the applicant for such permit to file a signed statement that
he Is licensed pursuant to the provisions of the Contractor's License
Law (Cbapler9 (commencing with Section 70W)of Division3ol the
Business and Professions Code) or that he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031 5
BUILDING PERMIT
'INFORMATION_
MISC. — REFER TO ORD
PERMIT ISSUANCE -g,pp I
VALUATION
-
-' `
S/FT.
EL CCONTR.' �A."r LIC. NO. ELEC.
C1��/ _ TOTAL v9/
t
QTY. . PLUMBING PEflM1T +FEE J
x •` `
PERMIT TO
/ �� -
L '
4f
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).): .
ALTER -DRAIN -WATER (EA.) 4.00 '
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will Jn lire work, and the structure is not
BACK FLOW PROTECT. DEVICE 2,00
OCC.GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. •4.00
intended or offered for sale (See. 7144, Business and Professions
Cade: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP �. •p. 4.00
SO. FT. FLOOR AREA
TOTAL'ACREAGE
property who builds or improves thereon, and who docs such work-
himsell'or t hrough his own employees,provided that such improve -
meals are not intended pr offered fnr sale: IL however, the building
or improvement is sold within One year of completion, the ..Go"
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) - '1.00 -
_
BUILDING USE
RES IND CON' PB Due,
F]❑ E:] E] ❑
INDUSTRIAL WASTE INTER. 20,00
licensed contractors -to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Cow does not apply
to,an Owner (31'.property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS- OVER 5 MA.) 1.00
-
ASSESSORS PARCEL NO.
Contracts for such projects with u contractor(s) licensed pursuant to
the Contractor's License Law. -
- SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I and exempt under Sec. ',B.&P.C. forthis
reason
yyATER HEATER W/VENT' 4.00
Owner - Dote.
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO,
- WATER TREATING EQUIP.. 4.00
-
WORKERS'COMPENSA'I' ION DECLARATION
• I hemby ulTumtllai I'hnvc acertificatc of cons.m to self -insure,
or a cerlificute of Workers Compensation Insurance, or a certified
ZONING'.`
ENG. SITE NO.
-
entry thereof(See 3800 Cah.C.I /1
Policy No. - - Company CYC4-i aJ 1 /N S, `p t_
. ❑
'
...
.
FIRE SPRINK
-ENERGY T-74
MISC. - - REFER TO ORD.
Cerliticd Copy is riled with the city inspection ch sion.
Applicant -•
Y❑ N❑
Y - N❑
' CER'I'IRIC'ATE OF EXI!MPTION FROM WORKERS'-
PERMIT ISSUANCE - .6.00 -
PlooD zorvE
,. A.L.U.C.
PLG. CONTE. , LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE -' ,- '
- (This section need not he completed it circ permit ais for olio
-.
Y ❑ N❑
`Y [3 IN E]
hundred' dollars (8100) or less.) -
- I certify that in'lhe performance of•the work for which this per-
'mit is issucA, I shall not employ any person in any manner so as to,
GTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
-
become subject to the Workers' Compensation Laws of California.
Datehtrtion, Applicant I '
'10
ALTER AR ADD TO MECH. ' 4.00
NOTICE APPLICAN'1% If, after making Ibis Certificate Of l:..
eiyou should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of,the Labor,Code, you must forthwith comply with.
such provisions or this permit shall he deemed revoked.
_
AIR HANDLING UNIT (TO 10 C.F.M.),- 3.00
FEE
- AIR HANDLING UNIT (OVER 10,000 C. F. M.) 5.00
,SEISMIC FEE
' CONSTRUCHON LENDING ACF:NCY
I hereby affirm Omt there is a construction ICliding for
EXHAUST HOOD (WITH DUCT) 2.00
-
'•
,agency
thc;parlbnnuhcc of the work fur which this pmmit-is=issued (Sec.'
3097 Civ.C.L -/ A' - "- -
MICROFILM
-
HEATING UNIT (TO 100,000 B.T.U.) 4,00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
q
6/ 9/
Lender's Name
rFL.
Leader', AJAress
:'I certify that l have read lhuapplication aildslam that lheaa,we
` VENTILATION FAN (SINGLE) 3.00
,
information is correct. I agree to comply with all city and county
ordinances and'state laws relating to building, Construction, and
PLUMBING
-
BOILER-COMP(3 H.P: Dr 100,000 B.T.U.) 4.00
BOILER -COMP 10 ver 100,000BTUISEEFEESCH.
MECHANICAL
'.hereby authnriee'represeniatives of,this city"col enter upon the
Amo c urutinned',prnperly for inspection Purposes
(We)'.grec to save; Pedro 1111ily and keep harmless the City of
" MISC:'- REFER TO ORD.
-
Cupertino against liabilities; judgments, costs .1111 Cxpcnses which
may in any way accrue against said City in consequence of the
• Ming Of this permit - -
J3 -SS
CONST. TAX
-
', PERMIT ISSUANCE 3.00
MECH: CONT. LIC. NO.
MECH.
TOTAL
TOTAL
grodam ot'Appllcanl/Conlrucbrr Uutc _,,,;,
OFFICECOPY r