4731 APPLICANT TOOILL IN INFORMATION WITHIN RED LINES — USE BA L . POINT PEN ONLY
BUILDING PROJECT IDENTI FICATI� PERMIT NUMBER
SDILDI.G 'APPLICATION & P �.ER I _xa_ X4731
�\ ADDRESS ,
4n�s E �� ILDING — ELECTRICAL—PLUMBING-MECHANICAL
- wrvER'S - — 'y _ PLAN CHECK VALIDATION.
NAME , �[I� Oct$ CITY. ELECTRIC PERMIT FEE,
-r PHTJ
�T
TRACTOR 0 P`/LOrrEt/L - OUTLETS-SWITCHES-RECEP '5.00/1.00
GLrf J (� i¢.uO. LIGHTING FIXTURES 5.00/1.00
f,ONRRAeroRs /��• APPLIANCES-RESIDENTIAL 4.00' '
DDRESS n4' I/ O •. -.
,-1e 7 PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEES P.C.NO.
r oR SIGNS 6.00
ENGINEER
LTC.NO, SIGNS TRANS. 3.00
ARCH.OR SS ENG. SPECIAL CIRCUIT 5.00 , PERMIT VALIDATION
ZIP TEMP.METER OR E INS. 15.00 -
APPLICANT'S MOTORS' '+' SEE FEE SCH. -
- ADDRESS /
SERVICE CH10.00
I. w
00 LICENSED CONTRACTORS DECLARATION [[[
< u yac 1 hereby affirm That I am.licenseA under provisions of Chapter 9 ISSUANCE DATE
i7 a (commencing with Section 7000)of Division 3 of the Business en<I llu BLDG. ELECT. PLG. MECH,
F N z Professions Cot n my license is in full for a fit / �7. - ❑ ® ❑ ❑
z o m — License I ss y///�.._..����fff�`Llc.Number- _ �L -
o m Dale. - /r 7 Cnntracm
< x Ic < ' N R-.� I BUILDING PERMIT
¢ ¢ a OWNER-BUILDIiR DECLARATION'
o a — INFORMATION
wIL LL y I hereby affirm that 1 am exempt frac the Contractor's License MISC.— - REFER TO ORD
k F = o a Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE. VALUATION $/FT.
6.00
m � Code:Any city sh county octal,
any reqstruitesap prior t toconstruct,mean e,also ELEC.CONTR, LIC.NO. y
¢ ¢ a O improve,demolish,or repair any structure,prior to its issuance,also ELEC. //d
O u requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
A w m he is licensed pursuant pro the provisions of the Contractor's License
H, i Law(Couple,9(commencing with Section 7000)of Division Sof the
E E o Business and Professions Code)orrthat be is exempt therefrom add GTY. PLUMBING PERMIT FEE
Se H o the basis for the alleged exemption:Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicantto a civil penidly ALTER-DRAIN -WATER (EA.)'4.00
of not more than five hundred dollars($500).1:
❑ I,as owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNrTS
thein sole compensation,will(S the work,and the structure is not
intended or offered
ract for sale(Sec. 7034, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law does not apply to s s owner of
property who hnlh his r improvesamplyeROn„addd that such improve-
Work FIXTURES-PER TRAP - 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such ibuildi e-
orimpvenotintendedorofl'end for lulu.l[hPIcT1QT,,TII building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or lder wilmav is a bi within pr year lie didtio t the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove 1,asoor neeose of sale.): - INDUSTRIAL WASTE INTER. .20.00 [] E � ,� ❑
❑ I,as owner of the properly,um exclusively contacting with '
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5'V.B. 5.00. ASSESSORS PARCEL NO.
and Professions Code: rhe Contractors License Law docs not apply
to at owner of property who builds or improves thereon,andwho LAWN SPR IN K LERS;.OVER 5 (EA,) 1,00
contracts for such projects with a enntractods)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 ^TRACT NO. PARCEL NO.
❑ l ant exempt under Sc,.—,BAP C,far this WATER HEATER W/VENT 4.00
reason
Date- • Owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COAfPENSATION DECLARATION, WATER TREATING EQUIP, 4.00 - -
1 hereby affirm that 1 have a certificate'of consent to self-insure,'
m a certificate of Workers'Compensalion,l n so.....c,or a c,rOwd -ZONING ENG.SITE NO.
- copy thereof(Sec.3800,Lab.CA
Policy No. ' Company _
Q -CI Certified copy is hcahy hvnished. .r - - - FIRE$PRINK ENERGY T44
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. ❑
O Applicant -Y N V N
CC w+ PERMIT ISSUANCE 6.00
Lu CER'TIPICATF:OINSAYION INS PRONN'ORKGRS' FLooO ZONE A.L.u.c.
W � COh11'IiNSA1'ION INSURANCE PLG.coNrR. uc.N0. PLG.
O r IThis section need not be completed if the permit is far one ^ TOTAL
Z hundreddollarOSIOD)or less.) -
U O .I certify that in the performance of the work for which this FEE SUMMARY
LL.I. mit is issood, I shall not ,,,play any pc sun in any manner no w CITY. MECHANICAL PERMIT FEE
Wheron ub c t tl c Workers'�pm[ s tion Lows of CuliG ia. -
y� D°le pphe°nP7£f ALTER OR ADD TO MECH. ' 4.00 BUILDING
} N NOT OO CAN'T: I ,a e taking His Certil icat•of T:x
H 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE -
C.� such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A000.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0000EM.) 5.00 SEISMIC FEE
1 hereby aRirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 - -
the performamce of the work for which this permit is issued ISec MICROFILM s
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U. .50
Lender's Addmss ELECTRIC
1 certify that 1 have read this application and state that the above - VENTILATION_ FAN (SINGLE) 3.00 -
information is cornet. I agree pro comply with all city vol county PLUMBING '
.ordinances and state laws.relating In IAl1ldlt19'COlSIRICII0JI, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby au thurire representatives of this City,
to Dater upon the
above mentioned property for inspection purposes. BOILER-COMP.IOvar 100,000 BTU)SEE FEE SCH. MECHANICAL
'
(We) agree to Save, indemnify and keep handless the City of MISC.- " REFER TO ORD. —
Cupertino against liabilities,judgments, cost,and expenses which `,PERMIT ISSUANCE.- 3.001CONST.TAX
- may in any way ac aguinst said City in onscquvna• of the
g id of this cr tL / MECH.CONT. LIC.NO. MECH'.
TOTAL TOTAL
tgnat arc of pp n v/Contractor -
- - ... - • OFFICE COPY' <