7070 (2) 'APPLICANT TO FILL IN. INF.ORMATION WITHIN.RED LINE&.-USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - - .PERmIr NumBER. e
q. ADDRESS
t
APPLICATION & PERMIT,
/� .gUILDING - ELECTRICAL-PLUMBING-MECHANICAL
7171
RS• ` ' PLAN CHECK VALIDATION
/1 PHONEa. _DTY- ELECTRIC PERMIT FEEACTOR'S
NAME _ - UTLETS-SWITCHES-RECEP 5.00/1.00 -
• LC.No :' ' 'f LIGHTING FIXTURES +5.00/1.00
A, ADDRESS ono - ,APPLIANCES-RESIDENTIAL 4.00
ADDRESS ' y
.. PHONE PANELS
ARCHITECT 5.00
DATE OF APPLICATION
ON t+, ..i SIGNS 6,00 . PLAN CHECK FEE - P.C.NO.
ENGINEER '
LIC.No.' !' SIGNS,TRANS. - 3.00
ARCH.OR ENG..- -
ADDRESS h SPECIAL CIRCUIT V, s .' ." S.OB PERMIT VALIDATION
zIP EMP.METER ORIOLE INS. 15.00 '
APPLICANT'S - +
ADDRESS, MOTORS SEE FEE SCH.
''
O L z o SERVICE CHANGE 10.00
r a o LICENSED CONTRACTORS DECLARATION
ce iw I hereby affirm that I am lieansed Imder Pnwisions'o(Chatue,9 -
or d leommencing with Seftion'7000)of Division 3 of the Business and ISSUANCE O E
F i Professions Code,and my license is in full force and effect L ELECT. G. MECH.
z o T License Class Lit,Nun.bar-
4 V r Date Contractor ' - -❑ ❑ . ❑
¢ ¢w¢ OWNfi R-BUILDIiR DECLARATION RATION BUILDING PERMIT
V
w 3.LL y• I hereby affirm that I am exemPPfrozo the Contractor's LicenseECONTH,
="'•' REFER TO ORD INFORMATION
H u O¢ law for the following Y.S.G.(Sec.7031.5,Boutin,S�nd PRifessions , VAL ATION S/FT.
Code:An 't T,ISSUANCE.
ito yn stir county which rcyuiresapermit[oamsfn¢Lalfeq ' 6,00 /'
¢0 improve,demolish,or repair any structure,prior to its issuance,also LIC.NO: - b ELEC.
u w esu requires ih<applicant fur such permit to file a signed statement that TOTAL '
he is liconsed pursuant to the provisions of[he Conln¢for's Lirense PER MITT
Fzi Luw(Chspter9fcomrnencingwith Section 7000)ofUivision3of the -
i o Rosiness and,Professions Code)or ihm he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H $ the basis far the alicged cxemptioh..Any violation of Section 7031.5
a- 5by any.Ihdirant fora - STORIES TYPE CONSTR.
'll permit subjegslhc apPlicam toacivil penally ALTER-DRAIN 4.00
of noLmore'than five hundred dollars(5500).): '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEV ICE
Ilmir s<ile Compensation,will Jn the work,and the slnsture is
of - 2,06 OCC.GROUP„• RES.UNITS
intended nr offered fonsale (Sec. 7044, Business anJ Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Coniracto[s License Eaw;does not apply In an owner of -
' property who buildstir improves tbeo.•on,anJ who docs such work FIXTURES-PER TRAP 4.00 so.PJ.FLOOR AREA TOTAL ACREAGE
himself or Ihrough,his'own employees,provided that such improve-
mentsarenotintendedoroffered�for sale.If however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 4.00
or imprnvemeol a so ld,wifhio onc.year of conhpletion,Ilia owner
r will have the burden of proving that he of to not build or im- GAS-EA.SYSTEM-OVER 4'(EA.)- 1,00 BUILDING USE
is for purpose of sale.).,. ' '-- . INDUSTRIAL WASTE INTER.' RES IND CON PR Onto,
I,as owner of Ihetpropmty,am exclusively contracting with 20.00 El ❑ ❑ ❑ ❑
I' ensed contractors to cons Dletihe project(Sec..7044,:Husiness LAWN SPRINKLERS-1 INC 5 V.B. 5.00
and Professions Code:1"he Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improve,thereon,and whit LAWN SPRINKLERS-OVER-5'(EA.)' . 1,00
Contracts for such projects with to contractor(a)lieensud Pursuant to
the Commctor's Icense'Law." SEWER-SANITARY=STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1""' t under Sec. ,R&P.C.for this
reusay " WATER HEATER W/VENT 4.00
Owne1.r - * Dade WATER SYSTEM 4.00
ACC.DATE ACC.FILE NO.
WO KI tS''cbnlP Date
IHicl.nRnTlWATER TREATING EQUIP. 4.00
I hereby affirm 1 h I have a certificate of consem V sehl insurc,
or a certificate of Workers;Compensutimi Insurance,or a certified ZONING ENG.SITE NO.
+ copy the,eol f Sve'3800;IAA f:.). _
_ Policy,Na: Company - t
0 -Ce IT filled copy is hereby furnished:. -
z z I:t,Carl ilicd ,copy•is fled with the oily,How division. FIRE SPANK
ENERGY TQ4
' F O Applicant- . MISC.- T REFER TO ORD. v IN v 0 NC]
CERTIFICAT Ii OFEXEMPTION FROM WORKERS' I PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.G,
'LL -COMPENSATION INSURANCE _ PLG.CONTR. LID.NO. PLG.
ICL O IThi, section need not be completed if the permit is for one TOTAL ❑ ' NCl Y
s
L) 2 lin ndreddhpma($100)ar loss.) - N�.
C7 O I certify that in the performance of the work fon winch ihkper CITY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F- mit is issued,I shall not employ.any person in any manner so as to
w bemrme subject to the Warkari Compcnsmion Laws a(Celifnmia.
0. . .Date Applicant ALTER OR ADD TO MECH. BUILDING D
},W NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex-
q,pp
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 ' PLAN CHECK'
provisions of the Labor Code, you must forthwith comply with FEE
I'.0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10j1 QF_ 3.00
CONS'fRUCTIONI:IiNDINGACCNCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE
Ihereby affirm that there is a construction lending agency for - EXHAUST HOOD (WITH DUCT) 2.00
the perfnrmance.of the work for which this permihis issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B'.T.U.) 4.00
Lender's Name -
Leader'sAddress HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC •
I certify that l haveread misapplication and sine that the above VENTILATION FAN (SINGLE) 3.00
� infonnafion is correct. 1 agree Go comply with all City and county
r mdinancm and state laws relating Io building construction, and _ BOILER-COMP(3 H.P.or 100,000 B.T,U.) 4.00 PLUMBING
hereby :ndherac representatives of this city to enter upon the '
above mentioneA property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to love, indemnify and keep'harmlec' the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judglihents, costs and expenses which
may in ny way accrue-against said City in consequence of the PERMIT ISSUANCE 3,00 CONST.TAX
gr:nhling d"Ibis periniU ! p�� MECH.CONT. LIC.NO: MECH.
f (j/) TOTAL TOTAL
X Signature to'App1 m/Contractor Date .. f
/ �' - OFFICE COPY _