6173 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING d '
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
6173
OWrvER'B - PLAN CHECK VALIDATION.
"AME QTV. ELECTRIC PERMIT FEE
- R PHONE
°
NA "cr°Rs ` UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
cONTRADTOR5 APPLIANCES RESIDENTIAL 4.00
AGOG EBB
ust� PH°NE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 8.00 PLAN CHECK FEEP.C.NO.
ENGINEER '��� '
sec.NO. SIGNS TRANS, - 3.00
ADDRESS
OR ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00
AMOTORS - SEE FEE SCH. )'
ADDRESS 0RE55
SERVICE CHANGE 10.00 �,�`/pT�
BE o LICENSED CON TRACTORS DECLARATION z Cl) !O?S/ase(
a i w I hereby affirm that 1 am licensed under provisions of Chapter 9 Q ISSUANCE O
A (commencing with Section 7000)of Division 3 of the Business and r BLDG. PLG: MECH.
z 1•mtf,Ra:ns Code,and 'cense is in full force an I effect
z 3 r� O �1
y- License Clnss—S�. Lia NumberEl /� O f1
9 mo iii Contmdor- �.(•dq7 ` �S•�w•�/ /L'J_,/ AVT J
a ?'
BE Q BE < OWNIi R-H UILUIiR DECLARATION 8 PERMIT
E
3 A r 1 herehy Affirm that I am exempt from the Contractor's License MISC.- REFER TO R ✓
tj
F w o a Law for
the following reason.(Sce,7031.5.Husinessandl'rofessions PERMIT ISSUANCE - B U VALUATION FT.
Code:Any city or county which requires a permit to construct.alter,
BE ¢ ¢ 0 improve,demolish,or mpair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ����
rl w m BE requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
in
Law(Chapter 9(commencing with Section 7000)ofUivision 3 ofthe ,Q,_���
3 4 o
:Ruins.and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE r w
¢ r a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 4,00
of not more than five hundred -
red dollars(5500).): /7e�-V .(vjp.rlkEt
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT._DEVICE 2.00 OCC.GROUP REB.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 C9, `r Pe4i da
-
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4,00 SO,ET,ELODR'AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended'or offered for sale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
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 OhM1er
prove for purpose of sole.). 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 ASSEB Hui 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 contractor(s)licensed pursuant to -
theContractor'sLicenseLaw. - SEWER-SANITARY-STORM EA..200ft/8.00 - TRACT NO. PARCEL NO.
❑ Imo exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 -
mason
Owner Data WATER SYSTEM '4.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-imeare,
or a certificate of workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished '
Z 2 13Certified copy is filed with the city inspection division. - FIRE SPRINK ENERGY T-04.
O Applicant MISC.- REFER TO ORD. Y'❑ N❑ Y ❑ N❑
~ rn PERMIT ISSUANCE
� -
CERTIFICATE COMPE EATIOI'INS FROM WORKERS' 8.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one 'e TOTAL Y❑ N Y 1:1 NE]
hundred dollars IS 100)of I.S.)
U O I certify that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in an manner so as to -
0 W become subject to the Workers Crynpensatioo La of Cal' ia.
y Dmc1v'71pe[Applicant"�r�r-^• ALTER OR ADD TO MECH: 4.00 BUILDING
>- N NOTICE TO AVPLICAN'1': If,afft making Ibis Certificate of Ex.
F Z emplion'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 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000CF,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 Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3,00
• information is correct.I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, andBOILER-COMP(3H,P.or100,000B.T.U.) 4.00
hereby authorize 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 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 any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit. / - - MECH.CONT, LIC.NO. MECH.
Tom. TQ�C� /e 6-Slyo TOTAL TOTAL
Signature of ApplicantjContractor Date'
OFFICE COPY