7115 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT 1 115
.DILmNG /y L ,I
ADORess -/
BUILDING-ELECTRICAL=PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
NAMe � `G OTYi ELECTRIC PERMIT - FEE
• .ONE /
cONTR oRs U, OUTLETS-SWITCHES-RECEP S.00I1.00
N E i
L.C.No / LIGHTING FIXTURES 5.00/1,00
CONTRACTOR'S /
ADDRESS PPLIANCES-RESIDENTIAL 4.00
_q! PHONE yA.T-Sig. PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 5.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
CIC,NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 1 PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSE:[)CONTRACTORS DECLARATION
is U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT- PLG. MECH.
'rF'm i Pnrl'essiov Code,and my license is in full ford a cc
nse t.
z o m LiceFrlase(.�Lm
ic.Number C ❑ ❑ ❑
a_ Z r Date 16-i/_ 7� Contractor
a x ii J BUILDING PERMIT
¢ Q w OWNER-BUILDER DECLARATION INFORMATION
w0
LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. lowinglfr tire but reason.(Sec.7031.5,Businc,,md Prlfessiunso¢ PERMIT ISSUANCE VALUATION S/FT.
Code:An '1 ormunt hichre requires mit to construct.alter, 5,00 OO
le or Y city p w y Icer
QQQ� IlnprOVC,demolish.Ol rl'pall dry at NClnrl',prior 10115155UanCe.aISD ELEC CONTR. LIC. ELEC. WV,
D¢ requires the applicant for such permit to file a sighed statement that TOTAL PERMIT TO /
ww he is licensed pursuant to the provisions of the Contractor i License
riaLaw(Chapter 9(commencing with Section 7000)of Division 3 of the
Bovines and Professions Code)or that be is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
d ;� by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(85000.):
❑ 1,as owner of the 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 Rot
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'The Cuntraetor's License Law does not apply to arowner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
' himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1INC.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 C N PB Other
prove for purpose of sale.). INDUSTRI AL WASTEINTER. 20.00 ❑ C1 El
0 1,as owner of the properly,am exclusively contracting with
licensed contractors hBusiness LAWN SPRINKLERS construct the project(Sec.7044, RINKLERS- 1 INC 5 V.B. 5.00 ASSESS S RCEL U.
and Professions Code:"Fhe Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts fur such projects with a contractor(s)licensed pursuant to
the ConO'actors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I and exempt under Sec.-,B&P C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sell-insure. ZONING ENG.SITE NO.
or a certificate of Worker, Compensation Insurance,or a certified
co y thereof(Sec.3R00,Lab,C.).
Pot I o. Company -
Q Certilicd copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z 'li co is deo with }1(c Riit inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O Applicant UE[ V N Y N
ft. W :RI'1FICA'1'17 OF li X1iMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N Y N
CIL O (This section need not be completed if the permit is for one TOTAL ❑ ❑ ❑ ❑
2 h....died dollars($100)or lcs.)
U O 1 certify that in the perfonnanen of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall ,of employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. BUILDING QO
O w Datc Applicant ALTER OR ADD TO MECH. 4.00
} y NOI WE TO APPLICAN'C If,after making this Certificate of Ex
Z c...ption,you slmuld become subject to the Workers'Conpensatiun APPLIANCE 4.00 PLAN CHECK
provisions of tine Labor Code, you must forthwith comply with FEE J
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.N ) 3.00
CONS'I'RUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 100MC.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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097.Ci,C.).
Lender's Nanc HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC .
Lender's Address
I certify that I have read this applicafion and state that the above VENTILATION FAN (SINGLE) 3.00
• In1'ornhaflon is correct. 1 agree to comply with all city and comity BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
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 suvc, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,Costs and expenses.),jets CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grant�p of this permit. MECH.CONT. LIC.NO. MECH.
(thea �J-06tca,. TOTAL TOTAL
Signature of Ap 'cam/Contractor Dale
OFFICE COPY