2753 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
%"IBUILDING PROJECT I DENTIFICATAK PECTI R
BU LDING APPLICATION & PER& [ �]
aOORESs ZAD J J
� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
(AME QTY. ELECTRIC PERMIT FEE
PHONE 9
NAME3
RacrORs - OUTLETS 5.00/1.00 � of
o tG✓•7?i✓1ALIC.NO
CONTRCONTRACTOR LIGHTING FIXTURES 5.00/1.00 aA
ADDRESS
- APPLIANCES 4.00
ODRE
/p HON PANELS 5.00 DATE OF APPLICATION
ARCHITECT L ALIF L PLAN CHECK FEE P.C.N0,
oR gNRu[:H_RcAtlAid1G�1 SIGNS 6.00
ENGINEEfl
LIC.No. 0402 SIGNS TRANS. 3.00
'(,ARC DDR,SS ENO. SPECIAL CIRCUIT 5.00 "yT�ALIo
a00R Ess /
1 Bt Ai 21P EMP.METER OR POLE INS. 15.00
APPLICANTS r..uL.IY q 3C(A MOTORS SEE FEE SCH, /A��
ADDRESS '(�VIb L.I+1 G $�3//Fi.11Nc. !!
t%p• Y 1 SERVICE CHANGE
10.00
DO o LICENSED CONTRACTORS DECLARATION Wow ^/ ww
a u O I hereby affirm That I am licensed under provisions of Chapter 9 Q�� }E
v, "' (commencing with Section 7000)of Division 3 of the Business and
y a BLDG. LECT," PLG. MECH.
o Professions Code, d hcens'e is in full fort a it if�fI
i o 'vl' S License lass_-142 Lic.Number 1 (y✓N 01 � 11
0 y F w Uat- A.ot $�/9RL Contractor aY-sE. -
a m BUILDING PERMIT
tc
A o OWNER-BUILDER DECLARATION
a
INFORMATION
w ; H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H .. o� law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION��I//j1 VIIIA.
Code:Any city or county which requires a permit to construct,alter, /MJI.0�
Qs Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIF NO. ELEC. (/(/[[��
G IS requires the applicant for such permit to file a signed statement that TOTAL
A w w lie is licensed pursuant to the provisions'of the Contractors License PERMIT T
r > Law(Chapter 9(commencing with Section 7000)of Division 3 of the
E i c business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE �`-
X I-$ the basis for the alleged exemption.Any violation of$ection 7031.5 STOfi IES TYP��,E��'C"""ONN��'STR.
a ; _ by any applicant fire permit subjects th5000.)cant taacivil penally ALTER-DRAIN -WATER (EA.) 4.00 / s �
of not store than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
sole compensation.will do the work,and the strucuuc is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Vw r�
Code:The Contractor's License Law does not apply to an owner oi' G/GGG///
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve.
himselfrmx a not through
or offered employees,
or moie. led that
howeverthe building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsale.). RES IND CON PB other
❑ I,as owner of the property,am exclusively contracting wINDUSTRIAL WASTE INTER. 20ith 00 ❑ i�l❑ ❑ ❑
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 properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1,00 / y 7..
contracts for such projects with a ecntractorfs)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00 �'-
reason
Date Owner. WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKf.RS'COMPbNSA'1'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sel Giroure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensai t err' ce[ktd"I ♦'
copy tlterc f(Se'. 8 u�.C. K e�P{ 'a�t�N sHTG. /�.gP
Q� Policy No. an r-
❑ Cer"' co is herebyfurni d. FIRE SPRINK ENERGY T]4
EICen file t inspection division.
Z fl
O Applicant - MISC.- REFER TO ORD. Y N❑ Y ❑
I- in - PERMIT ISSUANCE 6.00
cc Ln CF,RTIFICATE OF fiXEMPEION FROM WORKERS' PERMIT ZONE
LU COMPENSATION INSURANCE: PLG.CONTR. LIC,NO. PLG.
CL Z (This section need not he completed if the permit is for one TOTAL Y❑ �a-I�•�1y❑
hundred dollars(S 100)or less.)
U O 1 certify that in the pertorrnance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any munnerso us to
U become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
W ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Workers*
Compensation
sa i?x-
h ? emvisionyou ehauWbecome Code,
In the WOlDeit CComplyatinn gppLIANCE 4.00 PLAN CHECK
provisions io the labor Cit Shall
you mint forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCEION LENDING AGENCY AIR HANDLING UNIT(OVER 10pWQEM.) 5.00 SEISMIC FEE 3S°o
I herehy 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($ec. MICROFILM
3097,Civ.C.L 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 ceriify that I have read this application and state that(he above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all nsand county BOILER-COMPQ 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
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
OWC) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jndgmcnts, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may i any way accrue aµainst said City in consequence of the
gran' of this penn'L MECH.CONT. LIC.NO. MECH. /[/p �
'DTA` TOTAL T 6
Siµ 1 re ofApplicanl/Contract late
// 50 Z OFFICE COPY