6056 APPLICANT-TO FILL IN INFORMATION WITHIN-RED LINES= USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON - > PERMIT NOMBER
o, BUILDING APPLICATION & PERMIT �O^
AOORESS v 1
' BUILDING= ELECTRICAL-PLUMBING—MECHANICAL ;. 1.
v„
OWNER'S „ PLAN CHECK VALIDATION
(N�gF`M��-E (`•�1 - CITY. ELECTRIC PERMIT. FEE '
�/ L. - .•,PHONE
CONTRaCTO S ' `
Name UTLETS-SWITCHES'-RECEP ' 5.00/1.00
LE..O Q LIGHTING FIXTURES 5.00/1.00
CONTRACTORS ,
aoGREss APPLIANCES-RESIDENTIAL: 4.00 -
✓ PHONE Q1j"y PANELS - -5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P,C.NO.
OR. ., SIGNS• 6.00
ENGONE Ell - ' - t
uc.No. SIGNS TRANS. 3.00
( ADDRESS ENG, '`SPECIAL CIRCUIT ' 5,00 PERMIT VALI DATION
Z;P TEMP.METER OR POLE.INS. 15.00
APPLICANTS - //�� }}
AODREss ". ' MOTORS SEE FEE SCH. �J,
SERVICE CHANGE' 10.00
oo LICENSED CONTRACTORS DECLARATION
a vI hereby affirm Om(I am licensed under provisions of Chapter 9 _
H Q m Icomme a lig with Section 7000)of Division 3 of the Business and ISSUANCE DATE
BLOC. ELECT. PLG. MECH.
H w .I'rolessions Cnd and my license is in fulb force un effect. :❑ ❑ .-,❑, ❑
z:Z m License Class ,Y C.ritaNumber
for
O m H Uafc Cnnlmctor - -
Q y E
Ir w ' OWNER-BUILDER DECLARATION,• ?I' - BUILDING PERMIT
MISE. REFER TO ORD INFORMATION
w g a'r- I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
a o•j law for the following reason.(Sec.7031.5;Businessand Professions
'h- — 6 PERMIT ISSUANCE-,
Code:Any city or county which requires a permit lo'construct,alter, - 6.00' I ,�
BE a,Q 0 Improve,demOl Rh,Or relair.auy structure,prior to Its Issuance',also ELEC.CONTR.t, LIC.NO. _ ELEC.
O BE requires the applicant for such permit to file a signed statement that f' TOTAL
a w m a he is licensed pursuant to the provisions of the Conlmctors License PERMITTO
H i L.'w(Chapter 9(commencing with Section.7000)of Division 3 oflhc g
io Buslmess and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE aL"LVV
r$ the basis fur the alleged exemption.Any violation 11703 inn 703 LS V0 TYPE CONSTR.
by any applicant fora permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER (EA:) 4.00
+ of not more titan five hundred dollars($500).)'. e" ''
s❑ has owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE' - 2,00 OCC.GROUP RES.UNITS
,. their sole cm
opensalion,'will do the work,and the structure is not
intended it,offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00' g
Code:The Contractor's License Law docs not apply to lin owner of
property who la ilds or improves thereon,and who docs such work < FIXTURES-PER TRAP. 4.00 SQ FT.FLOOR AREA TOTALACREAGE
'
himself or through his own employees,provided that such improve-
mentsarenotintended or offered for sale.If,however,the building GAS,EA.SYSTEM-1INC.4 OUTLETS 4,00
or improvement is sold within one year of completion;/he owner-
builder will have the burlen'of proving tattle did not build or lot. GAS-EA.SYSTEM-OVER 4(EA.) ,1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL'WASTE INTER. .'.20.00 Res IND ' CON Pa Other
❑ 1,as owner of the property,tan exclusively contacting with - I] ❑ 0 ❑ O.
licensed contractors w construct file project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V-B:,' 5.00 - ASSESSORSPARCEL NO.
and ProfeWoos Code:The Cronmetah License Law does not apply - -
to an owner of property who.builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for such projects with a'cmntractot(s)licensed pursuant to -
theCmitmetor'sLicenseLaw. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCEL No. •,•I
❑ ['am exempt un der Sec.-,BAP.C.for this WATER HEATERW/VENT q,00 -
Hason
Owner Date WATER SYSTEM 4.00
I ACC.DATE ACC.FILE NO:
WORKFRS'COMPENSATION DECLARATION'. WATER TREATING EQUIP:' 4.00
I hcrehy.Minn tlml I,have u cert i Incite of crnSeat Rh self-insure, +
-
or a certificate of Workcri Compensation Insurance,
/otr a'certified - ZONING ENG.SITE NO.
copy Ihcreof(Sec.3800,Lab.C.)M4R 4vF jb
Policy Nn Company
Q E] CerliRcd npy IShereby IurmOW •QC. ` FIRE SPRINK ENERGY T-I4
z ❑ Cerl��Giyyp0,copy is fillh the city inspection division. _
O
Applicant ("` MISE REFER TO ORD. Y C] IN[D Y ❑ NO .
~ rn :PERMIT'ISSUANCE " 6.00
'CIiR TII°(CAT I:OI•I:XI:MPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
111 �' - COMPENSAflON INSURANCE PLG.CONTE. ILIC.NO.,'O PLG. y,❑ NEI v � N❑'
CL ('This section need not be completed if the permit is for one TOTAL
Z Z hundred dollars($100)or less.)
V O ' , 1 cerlily that in file performance of OR,work for which this per-
.U_ 1- mil is issued,I shall not employ any Iimson m D
in amp memor.so us TV, MECHANICAL PERMIT FEE FEE SUMMARY
O w hecome suhjecl to the Workers'Compensation Laws of California.
X Datc - Applicant 'ALTER OR ADD TO MECH. 4',00 BUILDING, �Q
} In NOTICE'I'O APPLICAN T:.If,after making this Cerf ifica[e of Iix
F_ Z uahplion,you should'become:subject to We Workeri Compensation APPLIANCE h 4.00 PLAN CHECK /
provisions of the Labor Code, you must forthwith comply with (0
V ! such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10=C.F.M.) 3.00 FEE —
CONS'fRiICTIONLENDING'AGENCY, r AIR HANDLING UNIT(OVER IO,000C.F.M.) 5.00 'SEISMICFEE
I hereby .11r. that there is a construction Ieacing 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 100,0008.T.U.) X4.00 �.
Lendcr'S e' • HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC +
I certify that I have read this application and stain that the.above VENTILATION FAN (SINGLE). 3.00
information is correct. I agree to comply with:all,city rand counly�. BOILER-COMP(3 H.P:Or 100,000 B.T.U.1 4.00 PLUMBING t ordinances and state laws relating to building construction, and - .. -
hereby uulhorife representatives of this.city'hh;enler upon dic BOILER-COMP(Over 100,0008TU)SEE FEE SCH! MECHANICAL
above-mentioned property for inspection purpomS. 1 _ -
(We)-agree to save, indenu fly and keep (harmless tire City DR. MISE.- REFER TO ORD. „ r
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX , '14 v
may in any way accrue against said City in consequence of file• PERMIT ISSUANCE 3.00 '
Branng of this PemhiL_ MECH.'CONT. LIC.NO. MECH, jl
'( � TOTAL .. TOTAL 7 U y
'Signa arc of Inn t(Contracror ]u[e 1
OFFICE COPY - �'