2361 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION . APPLICATION & PERMIT
aIIILDSes - - 2 3.61
AD E95
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
WNEF'S PLAN CHECK VALIDATION
"nm OTV. ELECTRIC PERMIT FEE
� IONEill!'` -7000
�. 'CONTRACTORS-
NAME CX7, UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
croR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
ADDRES
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P_.CAN.�O,/.
OR SIGNS 6.00r0
ENGINEER'
- uc.NO. SIGNS TRANS.NS. 3.00
ADDRESS ENG
SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDDRESSDAESSMOTORS SEE FEE SCH.
q
SERVICE CHANGE 10.00 /14/k
D o o LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 v ISSUANCE DATE
(conuneno(ng with Section 7000)of Division 3 of the Buslnessand
,
t, ¢vAwi BLDG. ELECT. PLG. MECH.
F G z Professions Code,and my license is in full force and effect.
d El
o i T w License Class Lic.Number
Mata Contractor.
BUILDING PERMIT
tt a w ¢ OWNER-BUILDER DECLARATION
o A u INFORMATION
X ; m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F mo J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
4 Code.Any city or county which requircla permit to construct,alter, SOO OOO
SE ¢Q O Improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
tc D ac requires the applicant for such pennB to file a signed dolens.ill 11,31 TOTAL PERMIT TO
w he is licensed pursuantto the provisions of the )ofl)ivisios License -
H i i naw(Chapter 9(femmes de)or Section isexemf Dtheref om ilie
and
ac 4 o Business and ProfessionsCode)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ICH $ the basis for the alleged exemption,Any violation of Sa civil
malty ST/O�R IES TYPE CONSTR.
u3 .. by of applicant fora Permit dollars(he0).): am(oacivil penalty ALTER-DRAIN f ' ��hW
of not mare than Coo hundred dollars(my em): y_
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GR UP RES.UNITS
Their sole compensation,will do the work,and the structure is not w`w
intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 B^ ./ �-
Code:The Contractor's License Law does not apply to an owner of
proporty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT. OOR AREA TOTAL ACREAGE
himself or thrrugh his own employees,provided that such improve- GAS -iINC.40UTLETS 4.00
ments are not intended or offered for sale.If,however,the building
" or improvement is Sold within one year of completion,lite 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•
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. .20.00
O I��N O Other
❑ d as owner of the property,he exclusively contracting with
licensed contractors to se Contra the project(Sec. 7044,Business LAWN SPRINKLERS-1'INC 5 V.B. 5.00 A SESSORS PARCEL NO.
and Professions Code:The Contractor's I-icense Law dues not apply �
to owner of property who builds or improves thereon,and who LAWN SPR -OVER 5 IEA.) 1.00
contracts
Wen 7 (7(rY
Cofor such projects with u conlracLLal sl licensed pursuant to
file Contractor's etnrs License Law. SEWER-SANITARY-STORM EA.200f1/6.00 . TRACT NO. PARCEL NO.
Iman
❑ am exempt under Sec. B.&P.C.for this
reasonWATER HEATER W/VENT 4.80 ^�
_ J C
Dale water WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORKERS'COMIT Arlo :CLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to salpinsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T�24
Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant _ 54 No Y E] NE]
p: rn PERMIT ISSUANCE 6.00
Lu - CF:RTI FICCOME OF PFN ATIO TINS PROM WORKERS' FLDDD zoNE -.eLrse�
W need not be completed
it the
PLG.CONTR. ' LIC.NO. PLG. Y❑ �
O hundred
section need not be completM if the permit is for one TOTAL
U 2 hundred dollars 151001 pe form
LL O I certify that h the performance of the nark for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 H mit ..issued,I shall not employ any person in any manner ut is to
O w become subject to the Workers'Compensation Lows of California,
Date Applicant BUILDING1,433a ALTER OR ADD TO MECH. 4.00
} H NOTICE: TO APPLICANT: If,after making this Certificate sa lix-
(... ? provision You should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you Intra forthwith comply with FEE 931.4
U such provisions or this permit sdeemed be deemed revoked AIR HANDLING UNIT(TO 10,0004F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 35.0
I hereby infirm (hilt them is a construction lending agency for EXHAUST HOOD (WITH DUCT( 2.00
3097srC' nce of the work For which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
,Civ
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I cerlily that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information n correct, I agree 10 comply with all city and county' PLUMBING
ordinances and Agee laws relating to building lciyandconstruction, and BOILER-COMP(3 H:P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,00(I 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue agai st mid City in consequence of the
grantingof s nit. MECH.CONT. LIC.NO. MECH.
9 go Y TDT"` TOTAL 2,399.45
..re a or ate
OFFICE COPY