2643 BU I LDING PROJECT I DENTIFI CATION Pe MIT
� noon'"ss0 APPLICATION & PERMIT 6 4 3
�ING �� �-7 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
wrvER'S / , ' ," a PLAN CHECK VALIDATION
NAME
� DTV. 'ELECTRIC PERMIT � C FEE•'
I,�, / �•U.��C HONE
ONTNAMEnacTORI OUTLETS-SWITCHES-RECEP 5.00/1.00
I td b > x7l u<.NO '� LIGHTING FIXTURES 5.00/1.00
rONTRIS
AcrDR's �!C 9C�i'P/`C� ",47-��L% PPLIANCES-RESIDENTIAL 4,00
ADORE
go, f'r .I,' vHONEy- C9 fi ' PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
sec.rv0. SIGNS TRANS. 3.00
ARCH,09 ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
ADDMOTORS SEE FEE SCH.
ADDRESS ESAS /ate
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION
w
Q 2 u 1 hereby affirm that I licensed under provisions of C 9 ISSUANCE GATE
N a (commencing with Sectionn 7000)of Division 7 0l the Businessness.and BLDG. ELECT. PLG. MECH.
H N 2 .•Professions Coit and license is in full far Si(e ❑ ❑ ❑
Li<enu CI ss Lic.Number 7
H w Date~Contractor
¢ ¢ w a OWNER-BUILDER DECLARA ION�i BUILDING PERMIT,'
o A u ..".INFORMATION•`• '.,
w3: ,�w 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO OR -
u O a Law for the following reason.(Sec.7031.5.Businevand Professions VALUATION S/FT.,
PERMIT ISSUANCE 6.00
Code:Anycitycountywhichstructure perminoconstruct,
uancalter. �[ r
Q Y improve,demolish,air repair h rWC tore,pa si n its Issuance,also ELEC.CONTR. LIC.NO. /-� C U U
¢ 6 o PY ELEC.
y w m LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT T 041-
he is licensed pursuant to the provisions of the Contractors License _
z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom aW CITY. :PLUMBING PERMIT FEE- �a@G S" 2i Alm
arI- the basis for the alleged a Kemp l ion.Any violat ion of Sec tion 7031.5 - _ STORIES TYPE CONSTR.
n ;_ by any applicant for a permit subjects the applicant oa civil Penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,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 not
intended or offered for IS(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
I,not hrough
ownemployees.for Sale.
If,ed that however.
the
improve- GAS-EA.SYSTEM-I INC-40UTLETS 4.00
mems are not intended or offered for ale.If,however,the building ••(
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 BUILDING USE p
builder will have the burden of proving that he did not build or im- RES IND CON PB OsM1er i{',
prove for purpose of the.). INDUSTRIAL WASTE INTER. 20.00 � ❑ ❑ � � 'f{
❑ L as owner D(the property,he exclusively contracting with s
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 See .B.&P.C.for this WATER HEATER W/VENT 4.00 s
reason
Date Owner WATER SYSTEM 4.00 ACG,DATE ALL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance.or a certified
copy thereof(Sec.3800,Lab.C.L 4
Policy No. Company 6wojy,0 12 5=
❑ Certified copy's hereby furnished.
Z Z ❑ Certified c P Is fi1p1W the wipeppon division. FIRE SPR INK ENERGY T44
F O Applicant -,. C il..-G�-( misc.- REFER TO ORD. Y ED N� Y [] N�
(L m CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
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 TOTAL Y N Y N
DZ hundred dollars(5100)or less.) .,14.
y .,*,,. • .,.. •: y.•:,-„ -- , ,I•.,..;.
U,O I certify that in the performance of the work for which this per DTV. MECHANICAL PERMIT-.'s, 'FEE +°•'I•rs''FEE SUMMARY.,- Tq4
LL I— mil is issued,1 shall not employ any person in any manner so as to `..
O become subject to the Workers'Compensation Laws of Califomia. . '• *'
O m Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex"
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK d"
provisions of the Labor Code, you must forthwith comply with FEE s.3
C.) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=11F.M.) 5.00 SEISMIC FEE e}�.
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work I'or which this permit is issued ISec. MICROFILM
7097,Civ.C.L - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UNIT IOVER ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
Icertify that l have read this application and slate that Omabove VENTILATION FAN (SINGLE) 3,60
information is correct. I agree to comply with sell city and County BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building cans....:.ion, and
hereby authorize representatives O1' this city to enter upon the BOILER-COMP (Over 1OD,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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran[' of this Perm r MECH.CONT. LIC.NO. MECH. -a", cT r
G TOTAL T J J �3
D-' ;TOTAL "'::a:.
nature.1'A licant Cumruc r Date
OFFICE COPY