4584 APPLICANT TO FILL IN'INFORMATION WITHIN RED LINES -Un BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON - PERMtr NumBER
_ auaowc APPLICATION & PERMIT
AooREss U
.// l.I.QJ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8
EH'a -- - -- -- - --- ��-----_ - PLAN CHECK VALIDATION
NAME pp
2w1 Q1146.61; OOTY- ELECTRIC PERMIT FEE L ,//'
�CONTRACTORS SWITCHES 5.00/1.00OUTLETSC
14
(� ..NO. LIGHTING FIXTURES 5.00/1.00
rONTRACTORs APPLIANCES-RESIDENTIAL 4.00
AOOREss ///����f}g
Rd-F, OrvEC/ r 6 PANELS 5.00 DATE OF APPLICATION
ARCHIT T SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEgp��
' CAV uc.rvar SIGNS TRANS.' - 3.00
ADDRESS ErvG. - LIDATION
ARCHER Qf1( FA SPECIAL CIRCUIT 5.00 - AV \�
zIP - EMP.METER OR POLE INS. - 15.00
ADDRESSv�wq 1
- - ''
DREss MOTORS' SEE FEE SCH.
DEC 1- SERVICE CHANGE - 10.00 ,,
ro O LICENSED CONT RACTORS DECLARATION "t City of CnpertinO
a v U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
< w (commencing with Section 7000)of Division 3 of the Businesx anA - - BLDG. ELECT. PLG. MECH.
r o i Prnfcesions n A my
2 license Is in full tr '1fe n�
' o m H� Dutc,-J_ Cap
¢ w a �'� OWN I?R.B Of L DER DLC LA RA'I'I ON ^ i BUILDING PERMIT
U INFORMATION
X
3 LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u. 04 Law for the following reason.(Sec.7031.5,Businessund Prolessions, PERMIT ISSUANCE 600 vnwnnoN $/FT.
Code:Any City or county which requiresa permit toconstruot,ulleq {(�/(
ac ,ar ¢ p impmve,'demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC. '�^
0 a requires the applicant for such permit to file a signed statement that t TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
i a
Law(Chapter 9(commeneug with Sect on 7000)of Division 3 of t hu - .fes 1�I
s Business and Professions Code)or that he is exempt therefrom unit QTY. PLUMBING PERMIT FEE ��'Nf
a t-$ the(iasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. -
o3 _ by any applicant for a permit subjects the applicant too civil penaltyALTER-DRAIN -WATEfl (EA.) 4.00
of not more than five hundred doll .
ars IS5001.), '-
❑ J,as owner of file property,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 (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The 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 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or tivough his own employees,provided that such improve.
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or Intprovernert is sold within one year of completion, the,ownnr GAS-EA.'SVSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsu)eJ. INDUSTRIAL WASTE INTER. 20.00 RES tND CON - PB Omer.
❑ I,as owner of the property,ant 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 diction,and who LAWN SPRINKLERS-OVER 5 (EA.) '1.00
contracts for such projects with it contractons)licensed pursuant ti.
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/8.00 TRACT No. PARCELNO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Dole - Owner - WATER SYSTEM 4.00 ACC.DATE ACC FILE NO.
WORKER S'COMPHNSA7'ION DECLARATION - WATER TREATING EQUIP, 4.00
I hereby affirm that I have uc�,,ccrrI�j cum of c:mwmt to self-insure,
or a certificate n( ' I � olion last rance!or it certified ZONING ENG.SITE NO.
copy ther�htw`T'...Iocl0 Lrrny /_ -
Poliq No Company 1L�.AAXT�0.-
Q ❑ Certified copy is hereby(uresis ted. FIRE SPRINK_ ENERGY T 24
Z ❑ Certifi• is fled ith the city inspection.Aivisiolt MISC. REFER TO ORD.
F APIP cant oty TC.[� ' Y ❑ N❑ Y ❑ No
- CE.R'TFICA'I'li OI'IiXENIPTION FROM WORKIIRS, PERMIT ISSUANCE 6.00 FLOOD ZONE A1.U.C.
' L �_ COMITNSA'I'ION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ NE] Y ❑, N❑ '
d (This section need not be completed if the permit is lot one TOTAL
Z) Z hundred dollars(SHAD.,less) _
U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT ,. FEE . FEE SUMMARY -
LL F mit is issued„I shall not employ any person'in any manner so as to
O
L) become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. q,pp BUILDING
} m NOTICE TO APPLICANT: It,after making this Certificate of Ex-
F Z emptlon,you should become suluelt to the Workers'Conipunsution APPLIANCE :4.00 PLAN CHECK
provisions of the Labor Code, you outsd forthwith comply with FEE
U such provisions or this permit shall be deemed revoked:• AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00 r
CONSTRUCTION LENDING AGENCY f' AIR HANDLING UNIT(OVER 10,000QEM.) 5.00 SEISMIC FEE rJD
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH D_UCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Narm HEATING UNIT(OVER 100,000 B.T.U.0.50
Lender's Address ELECTRIC
Icertifyflint l have read this apphewionand state that the ahove 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, Slid BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this tidy 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 the City of MISC.- " REFER TO ORD. -
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
-' tray in any wayaccrueagainst said City in consequence til' PERMIT ISSUANCE 3.00
grants it, MECH.CONT. ' LIC.NO. MECH. -
TOTAL TOTAL
Signutu of Applica t/ ntractor - Dude
.' OFFICE COPY ,