4836 ,W,A.PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
UI LSI NG PROJECT I DENTI FICATION PERMIT UMBER
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C /APPLICATION & PERMIT
CK
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4836
e
NAME �'"�' -� n,D ;L110 PLAN CHECK VALIOATION
`•T -111 DTV. ELECTRIC PERMIT FEE
u NF ® a 34,0;17
�rvAMe ACToos -t ,. UTLETS-SWITCHES-RECEP 5.00/1.00 To f/ "' �6/�
� uc.NO, LIGHTING FIXTURES 5.00/1.00 �' 00
CONTRACTORS s •� � (+ PPLIANCES-RESIDENTIAL 4.00
ADDRESS
S ' PHONE 287= Q PANELS 5.00 DATE OF APPLICATION
nCHITECT, - BOBE SIGNS. 6.00 PLAN CHECK FEE P.C.NO.
OR �tx
�/ EN EEO OWWO -
uc.No, SIGNS TRANS. 3.00
ARCH.OR ENG- M�1 SPECIALCIRCUIT 5.00 PERMIT VALIDATION
A55 Qq7
_T :IP EMP.METER OR POLE INS. 15.OU
I
APPLI rs MOTORS SEE FEE SCH. J
ADDRESS
p SERVICE CHANGE 10.00 AN
H
DO 1 LICENSED CONTRACTORS DECLARA'T'ION
¢u u I hereby affirm that 1 am licensed under provisions of Chapter 9 I�
l.
z w (emenu cin,with Section 7000)af.Divailm 3 of the Business and
ru ¢ BLD E C PLG. MECH.
F D z Professions Code an m license is in full force and effect. ❑ ❑ ❑
zo i m License Class a f� Lie.Numberr.��$���'fy(y' DO
-
F m r J
Late�n5f Contraclor�I�/ -
a s4 s a v, BUILDING PERMIT
� ¢ OWNER-BUILDER DECLARATION
a 0 to u INFORMATION
w 3. LL 1 hereby affirm that 1 :un exempt from the Contractor's License MISC.- REFER TO ORD
u0j Law fertile following reason.(Set.7031.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION
0� Code:Any city arcmmty which requiresa permit loconsHacLalter, 7 0 000
IFa O improve, Or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. _
u w m 2 requires the applicant for such permit to file a signed statement that TOTAL PERMIT T0O��
he is licensed pursuant to the provisions of the Contractors LicenseC.E ,6
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Bushes and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT. FEE .S BLL O L
g
Ie r$ the basis for the alleged exemption.Any violation of Section 7031.5 TO IES TYPE CO R.
n , by any applicant for it permit subjects theappl earl toa civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollars(5500U: •R.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. EV ICE 2,00 OCG GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not __
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,ARN'CON D. 4.00 --_ 06- .2-1
_ q -
Code.The Contractor's License Law does not apply to an owner of R/
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• mentsf re through his own employers,provided thin such improve-
ments not intended,ed or offered for sale.lf,hd flm, act,
tile building GAS-EA.SYSTEM-I INC.4OUTLETS 4.00 / 47,000
or improvement is sold within one,year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or in,-
Prove for Purpose ofsale.)' INDUSTRIAL WASTE INTER, 2000 RES IND CON PB Omer
❑ 1,as owner of the property.am lu
excsively contracting w .
ith ❑ ❑ ❑ ❑ ❑
licensed contractors tD construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cod, File Contractors License,Law docs not apply
tO an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 `36 ?-
tile
roContractor's
onts forrush ceeprojects with a cote ractorl5)licensed pursumtt to SEWER-SANITARY-STORM EA.200ft/8.00
Cait fors
SLICrw. TRACT NO. PARCEL NO.
❑ Inst exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT-, 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to selbinsure,
or a certificate of Workers'Compensation Insurance,orp certified ZONING ENG.SITE NO.
copy thereof e.J800 tb.0
Policy No. c ompan
O ❑❑ Certified copy is hereby furnished.
Z Z /�Certifed Sy�y . fipd III It C1t�,. save t ivieion. FIRE SPRINK ENERGY T-24
O Applicant_�(NeKsL,.-�a'l I ISfy'll MISC.- REFER TO ORD. Y ❑ NQ Y ❑ N❑
CC LO CERTIFICAT E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O [Phis section need not be completed if the permit Is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars(SIO0)or less.)
U O 1 certify that in the performance of tile work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any mmnner so as to
O W become subject to the Workers'Compensation Laws of Cxlifomia. `
y Dare Applicata ALTER OR ADD TO MECH. 4,00 BUILDING 4Y
} to NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
? einptiou,you should bee nm suhjem to tiro Workers Compensation APPLIANCE _ 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 100WCF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE S S
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance lie w r for w C tl i e it is issued(Sec. MICROFILM
3097,Cie CA HEATING,UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name•�
Lender's Address_� I,.. _�NQ HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
I certify that ha
I vv read tllis application and state that the above VENTILATION FAN (SINGLE) -
indimalc s n correct I agree to comply with all city and county. PLUMBING
ordinances and state taws relating to building l city uction,and co and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH, MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save. indemnify and keep harmless theCityat 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
IT anting of this permit MECH.CONT. LIC.N0. MECH.
TGTAL TOTAL
n, um.1 p unl ontmcmr Date
l Sod 2crt +.1 r2r�o6,OF iCE.COPY