4491 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BA L POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICA - PERMIT NUMBER
RuaolNc - APPLICATION & PER 4491 p n q
nooREss DING — ELECTRICAL-PLUMBING—rMECHANICAL L� L�`�•
• OWNER'S •(o - - - - — — PLAN CHECK VALIDATION
NP"'E TY. ELECTRIC PERMIT FEE
IF f ..
NgmTERacToas rr OUTLETS-SWITCHES-RECEP 5.00/1,00
_ _ Q LIC.NO LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPL IANC ES;RE SI D ENTIAL, ,4.00
ADDRESS
HONE �J PANELS
5.00 GATE OF APPLICATION
ARRCHITEC _ 'SIGN$ - - 6,00 PLAN CHECK FEE P.C.NO..
ENGINEER -
' LIC.No. ,. SIGNS TRANS. '/' 3.00
'ARCH.OR ENG. PERMIT VALIDATION
ADDRESS ` SPECIAL'CIRCUIT 5.00
ZIP JTEMP.METER OR POLE INS. 15.00
APPLICANT - MOTORS SEE FEE SCH.
ADDRESS
- SERVICE CHANGE 10.00 . .
0 0 0♦ LICENSED CONTRACTORS DECLARATION
E,u 1 hereby affum that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y'z "' (eommerem wish Section 7000)of Division 3 of the Business and
¢ y g µ BLDG. ELECT. MECH.
r o z 1'rolessions Code,J I y license is in full force, w. ❑ ❑ ❑
D o w — License C as Con Number J '—
o Z'r Uum Contractor
r —
a m sa BUILDING P RMIT
¢ ¢o n OWNIi R-IIUILDIiR DECLARATION - - INFORMA ION
E:
fi e. w 1 hereby affmn that I am exempt from the Contractor's License MISC.— _ REFER TO ORD ' VALUATION
r IAO J Law for the following reason.(Sec.7031.5,BUShle'ssalld PTONSsiobs PERMIT ISSUANCE - 6100 $/FT.
Code:Any city or county which requires a permit to canstnnct cher,
¢ to a ¢ ,O improve,demolish,c r repair any stmcture,prior to its issuance,also ELEC.CONTR. •' LIC:NO. ELEC.
O a requires the applicant for such permit In file a signed statement that - TOTAL
c m m hContractor'sPERMIT TO
e is licensed pursuant to the provisions of the License '
is Law(Chapter 9(commencing with Section 7000)of Division 3 offle
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
2 F $ the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penally ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(4500).):
0 h as owner of the pmPerty,or my enlpluycds with wages as BACK FLOW PROTECT. DEVICE 200
their sole compensation,will do the work,and the stmctur ,
e is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Probessions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -
Code.Tine 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 d se.FT.PLooR AREA TOTAL ACREAGE
. -himself or through his own employees,provided that such improve-
ments'are 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- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 -euILOIN USE
builder will have the bu Nen of proving that he did nor build or im-
provefor farposc ul'salu.l. INDUSTRIAL WASTE INTER. 20.00 RES wD PB Omer
Cl I,as owner of the property,am exclusively contracting with ❑ ❑ M ❑_ ❑
licensed contractors to construct the project(Sec 7044,Bisincss LAWN SPRINKLERS- 1..INC 5 V.B. 5.00 ASSEBBORB AI CEL NO.
and Professions Code:1'he Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contractor(s)licelised pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
"❑ lam exempt under Sec. ,B.&I'.C.Ibr rois WATER HEATER W/VENT - 4.00.
reason
Date Owner WATER SYSTEM 4.00 Ace.DATE Ace.FILE No.
WORKERS'C011PFNSATION DECLARATION WATER TR EATI '4.00
- I hereby afYinm that I have a eertifiade of consent lu sell'-insure. ZONING
or a certificate of Worker's'Compensation Insurance,or a wrtil'ied ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L
Policy Na Company -
O O Certified opy ;hRrcby'fomitted. FIRE SPRINK ENERGY T24
,t Z 2. �crtiHed filed III y inspection division. -
O PA plaont IMISC. 0 TO ORD. Y ❑ N❑ Y ❑ N❑
� LO CERTIFICATE 01717XI-MPI'ION FROM WORKERS* "PERMIT ISSUANCE 6.00 �(fQ FLODD ZONE A.L.u,C:
LL > '` COMPENSATION INSURANCE PLG C NTH, LIC.NO. pLG.
(This section need not be completed if the feRmi is for one TOTAL �� V❑ N❑ 'V❑ N❑
2 hundred dollar,IS 100)or lass.)
U O 1 certify that in the performance of the work for which this per 6TY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is iSo ed, I Mm11 not employ any person in any manner so as to
O W become subject to the B'orkens Coen
mpsalmn Laws of.Calil itrow. -
a Dae APPIi°:rotALTER OR ADD TO MECH. 4,00 BUILDING
} rn NO'ricE 1'0 APPLICANT: If,after making this Certificate of Ex.
F" Z emPtion,you should lieanno subject it,the Workers'CrIRPcn6atkm APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this Permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING,AGENCY' AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
..I hereby affirm that 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 Add. HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's - ELECTRIC
I certify that l have read thisapplication and slate that IIIc above VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all cily,:md county PLUMBING
ordinances and state Jaws relating fo'.builJing rnnttruct iqn, and BOILER-tbMP13 H.P.or 100,000 B.T.U.) 4.00 -
hereby aulhoriae 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 oto save, indemnify and keep hartnlcss the Cily of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnmm , costs a d expenses which CONST.TAX
may-in any y accrue a ain t s City in consequence of the PERMIT ISSUANCE 3.00
grantin N1 jpennit. MECH.CONT. . LIC.NO. MECH. -
TOTAL TOTAL
Si,mtumof Applicnn /Cmnmctar Ila[
OFFICECOPY ,