1015 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY,-
BUILDING PROJECTIDENTIFICATION 71
R T UMBER
BUILDING _ APPLICATION & PERMIT
ACODR
ELECTRICAL-PLUMBING
. -MECtHANICAL
101
5BUILDING
DINNER
� T- PLAN CHECK VALIDATION
L 1L Ye- -
Z40 NAME OTY hTMaT 'R ' FEE
(io`04�II 1
`.
NAME OUTLETS
/ UTLETS-SWITCHES-RECEP 5.00/1.00
1C.NO W9M LIGHTING FIXTURES 5.00/1.00
COONNTTRAAACTORsS✓ PPLIANCES-RESIDENTIAL 4.00
A/7o G"•i1111��s7 oxe PANELS 5.00 DATE OF APPLICATION
ORRCHITECT �� SIGNS fiAb PLAN CHECK FEE P.O.NO.
ENG INEEA�j� /�l,�q 3,00
-2!!C L LIC.NO. SIGNS TRANS. •�
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
zip TEMP.METER WILE INS. 15.00 /-�
APPLICANT'S MOTORS 'SEE FEE SCH. / )JAL
ADDRESS
SERVICE CHANQb 10.00
woo LICENSED CONTRACTORS DECLARATION
a 0 I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w
Z. w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D& Professions Code my license is in full for fay
0 B o License ss _ Lk.Number TH ❑ ❑ ❑
,a H j Dete - Contracto /(�y..
e w < OWNER-BUILDER DECLATtAT h BUILDING PERMIT,--
' 0 A U REFER TO ORD r".•' :i INFORMATION.'•:
3 n I hereby affum that I am exempt from the Contractor's License MISC.- VALUATION
w 0 7 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
www Code:Any city or county which requires a permit to construct,alter, JQ Vsr
Q QImprOVe,demolish,O! epalf any structure,prlOrtO IIS ISan ,aI50ELEC.CONTR. LIC.NO. /
ELEC.
-0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X w he is licensed pursuant to the provisions of the Contractor's License
r¢>0 Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4) yIN'A,.'AVV>X+
Business and Professions Code)or that he is exempt therefrom and OTV '•'$ y t11 PLUMBING PE RMI to l r 4n� aFEE>*'
zJz Z O Y1T 4y h sY It M •% t Yi� L., ,
w. thebasisthe alleged exemption.cts(he applicof ant
roaction70315 - .,4. 'a.�.I +.TiE u,).r1' ,} ;,.,y n� ., STORIES TYPE CONSTR.
d 3 � by any applicant fora hundred
dell...(he 0).): ant too Civil penally ALTER-DRAIN St VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon.and who does such work F IXTUR ES-PER TRAP 4.00 $0,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such mimprove- GAS-EA.SYSTEM•1 INCA OUTLETS 4,00
t. mes an not intended or offered for sale.If,however,the building
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 im- RES IND CON PB Ocher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting 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:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
❑ lam exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that l have a certificate of Consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compen`sation In;urance,Ura certified
copy thereof IS.C.3800,Lab.Cj.G
Policy No. Company
0 ❑ ified is he by fumes ed. FIRESPRINK ENERGY T-24
z Z fJ/Cerlif,a d wiyylylh ion di "
Applicant /+' MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
Hy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
fL CE IFICATE OF EXE ION ROM WORKERS'
LU COMPENS ON IN RANCE PLG.CONTR. LIC.NO. PLG.
a Z (T s section need not sled if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hu red dollars($100)or less.)
U O I certify that in the performance of elle work for which this per. OTVMECHANICAL PERMIT' FEE FEE SUMMARY't
.
LL 1- mil is issued,I shall not employ any person in any manner so as to _ p
0 W become subject to the Workers'Compensation Laws of California. BUILDING /�3 01,f
D• Date Applicant ALTER OR ADD TO MECH. 4.00
} 0 NOTICE TO APPLICANT: If,after making this Certificate oEx-
F Z 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1O=C.F.M,1 3.00
CONSTRUCTION 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
Lenders Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state(hat the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COIs�(3 H.P.Or IO0,000B.T.U.) 4.00
-� hereby authorize representatives of This city to enter upon the BOILER-COMP IOvar 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in an way accrue against said City in consequ ce f the PERMIT ISSUANCE 3.00
grantin Itisper i4 MECIRCONT. LIC.NO- MECH. -" '.'• .+
A. -.,•,5(.4 y.
f/� TOTAL TOTAL":':" 3�O
Sign Teo Applicant] traclO Uate
OFFICE COPY