6537 T
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
_ , , APPLICATION & PERMIT
�D `
�' AODRES �OV 1�n
)V] ATr\XI BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6537
p OWNEC�RI'j 0DO PLAN CHECK VALIDATION
/ "AM' ';S7_7 1(,CxJCITY. ELECTRIC PERMIT FEE
PHONE G�t 5 O
N M ACTORS 1ff1�111 ElI --a6ay� UTLETS-SWITCHES-RECEP 5.00/1.00
j' Nf 1T.S�OC, LC.NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
NTRAS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 (;ku
ADvess
ADDRESS l's MOTORS SEE FEE SCH.
SERVICE CHANGE 10.001/13//�'/
C o LICENSED CONTRACTORS DFCLARAI'[ON
¢u 1 hereby affnn that I urn licensed under provisions of Chapter 9 6-1 ISSUANCE DATE
may (commencing with Section 7000)of Division 3 of the Business and R ELECT. PLG. MECH.
F ProlcssioJ_e sc is in full forcv�a�JI's,5f. ❑ O ❑
z o P, License C Lic.Number
9 F w Dam Contractor A Sem
a x s - WIG PERMIT -
¢ ¢ a OWNER.BUILDER DECLARA'f10N 'I
oo `a MISC.- REFERTO ORD %J
!. RMATION
se 3 LL w 1 hereby ilfino that 1 am exenqu from the Contrminrs License VALUATION 5/FT.
H .. oa Law for the following reason.(Sec.703 L5.'Buxinessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
QQ¢ p Improve,demolish.Or repair any structure,prior to IIs Issuance,also ELEC.CONTR. LIC.NO. ELEG MITu
D¢ requires the applicant for such penult to the a sighed statement that TOTAL PER[NIT.T�
a w m u- he is licensed pursuant to the provisions of the Contractor's License ((�`//Vv'')'�,
H Z i Law.(Chapter 9(commencing with Section 7000)of Division 3 oflhe
4 Business and Professions Code)or that he is exempt Omrnfrom and CITY. PLUMBING PERMIT FEE
¢ ro thNitsis for the alleged exemption.Any violation ofSectkm 7031.5 STORIES TYPE CONSTR.
a3°2 by any applicant for a permit subjects the applicant In a civil penalty ALTER-DRAIN&VENT-WATER IEA.14.00
of not more
than five hundred dollars($500).):
❑ I,as than
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 sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply loan owner ed
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 employees,provided that such improve-
mead
is are not intended leu sale.It,however,the building GAS-EA.SYSTEM-1 INC.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 ire- RES IND PB Omer
pros,for purpose olsalc.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as n ❑ ❑ E) F-1tar of the property,um exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSO SPARCEL NO.
and Professions Code:'I'he 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
he Cont lbs su Licene Lwinhacuntrectorf sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Iamexemplunder See. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACG FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a cert ifirme of Worker,'Crum pe "tlrion Insurance,or a cerlifa
copy lhercof(Sec.3800.Lib.C.l. ,y)Lc,yLN e:aj SY,�-L^ tl
'Policy No. Company
Q ❑ Ccrtific f1yls r yfumrsh FIRESPRINK ENERGY T-24
Z 2 Applicant i _ ed wird city inspco ' nn div ;n. MISC.- REFER TO ORD. Y ❑ IN❑ Y ❑ N
O
C rn C17R I'I PICATE 015TSIPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu >_ COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG.
CL O ('Phis section need not be completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
Z) Z hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEESUM NIARY'";
LL H' mit is issued.I shall brut eon ploy any person in an,munner so as 10
U
Obecome subject to tile ie Workc, Compensation Laws of California.
w Date Applicata BUILDING
a ALTER OR ADD TO MECH. 4.00
} ro NOTIC17 TO APPLICANT: If,after making this Certificate of Ex-
H 2 emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you most lixthwilh,comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RMJ 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(Sce. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Addle HEAT[NG U N IT(OV ER 100,000 B.T.U.17.50 ELECTRIC
ss
1 certify(hat 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relining m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEES CH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemni y and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,ju inenfs, costs and expenses which CONST.TAX
may ip ahy y' ecru, ago' st Yid Cfly in consequence f t e PERMIT ISSUANCE 3.00
gm I`/ M mit. i ECM.DONT. LIC.NO. MECH.
�� TGTAL TOTAL j
Ignalure of Appli t onlractor Uatc
OFFICE COPY