4730 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
13UI LDI NG PROJECT I DENTI FICATION APPLICATION & PERMIT PERMIT NUMBER
BVILOING
4730
ADDRESS
� //000 �C/•Q. �J BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NamE �'"� //� 7� CITY. ELECTRIC PERMIT FEE
)� Nµy C�fM , PHONE /�/ 4
NCONTERACTOR5 OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME ,�,� o'
O5r a I CN j6I! IC LCNO3� ?� LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
[Iq,- �OZ / / '/ PPLIANCES-RESIDENTIAL 4.00
/j y2 /r/�QB(( /• �•C• PHOrvE (x"//71 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.0.NO.
OR
ENGINEER
' uc.Nti. SIGNS TRANS. 3.00
RCH.OR ENG. - SPECIAL CIRCUIT $,00 PERMIT VALIDATION
ADDRESS
Z" EMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE PAID
10.00 ��7(
w
02 LICENSIi I)CONTRACTORS DECLARATION I�
v v I hereby affirm thin I ton licensed under provisions of Chapter 9 1 ISSUANCE DATE
H 3 H (commencing with Section 7000)of Division 3 of the Business:toil BLDG. ELECT. PLG. MECH.
Professions Cod- and my license is in full force and effe
z o m License Clgss -/_Q Lic.Number3l-� /s El El 11o H ° Date_(.Z/4-f17 ContractorLWf City Of Cu
pertino BUILDING PERMIT
M IF LL u OWNER-BUILDER DECLARATION INFORMATION
wa N I hereby uRirm that I ao exempt from the Contractors License MISC.- REFER TO ORD
1. 04 Law forthe following reason.ISec.7031.5.Businessoull'rolcoions PERMIT ISSUANCE 6.00 vnLuanON
� - 0 Code:Any city orcounty which requires a permit to construct.alter.
20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- Drequires the applicant for such permit to file u signed statement that TOTAL PERMIT TO
wm LL he Is licensed pursuant to the Provisions of the Contractor's Ciccone ry rG�
Fzi
LAW(Chapter 9(commencing with Section 7000)of Division 3 of the k-L
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any vi.hhou of Section 7031.5
STORIES TYPE CONSTR.
d , by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
mns
their sole copeation,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
property who builds or improves thereon.and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own mnploycc,,provided that such in'Provo-
enta
mare not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the ownery GAS EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that h - . , .
e Aid not build or int- RES IND CON PB Omer
prove for m'.W of sulcJ. INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,ams exclusively contracting with
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 Contractors License Law docs 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
the Contractors License Law. $EWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt muter Sec. .B.&I'.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK[iRS'COMPI!NSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to Wi Givure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a c• tifioJ
copy thereppII��IScc-.3$Q0.Lub.C.).
Policy No.I✓6�2 hereby
1Y
Q 0 Certified WAY is hereby l with til FIRE SPRINK ENERGY Tao
z zT ❑ Certified dopy,g rhied with tile inspection division. MISC.- REFER TO ORD. v N v N
`1 ApplicanlJC3./_/JLI✓_�(GcafCLC ❑ ❑ ❑ ❑
W CERTIFICA'1'1:OF:EXE,%WTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LLI ? COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
n- O IF his s onal need not be completed if the permit is fur one TOTAL v❑ NE] V ❑ N❑
Z hundred dollar,IS 100)or less.)
L) Q 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
IL H mit is issued,I shall not enhploy any person in any mmoner so as to
Q U become subject to the Workers Compensation Laws ot'Californiu.
Date ApplicantALTER OR ADD TO MECH. 4,00 BUILDING
} y NOTICE TO APPLICANT: 11
,after making this Certificate of Et-
F ? alnption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Colic, you .,lust forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC .r
Lender's Address
I certify that I have read this application and star,that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to Comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
10
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned Property Bx inspection Purposes.
(We) agree to are, indemnify and keep harmless the City of !-EC.
MISC.- REFEfl TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accru agai t sal City in consequence of thePERMIT ISSUANCE 3.00
grantin 1 this PennigffI4 CONT. LIC.NO. MECH.
�2/y oTAL TOTAL
Si4 shire of Applicant/Contrator Date
OFFICE COPY