5114 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
,r BUILDING PROJECT IDENTIFICATION - PERMITNUMDER
�/ BUILDING APPLICATION &,PERMIT
4ADD" BUILDING—ELECTRICAL—PLUMBING—MECHAN 5114
eaPLAN CHECK VALIDATION
a•S3 ""W " t' '''V'ELECTRIC� ) ` I�I g�TO S
NAME OUTLETS-SWITCHES-RECEP 5.00/700
LIC.NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS- 5.00 DATE OF APPLICATION
ARCHITECTSIGNS -g BD PLAN CHECK FEE P.C.NO.
Ofl
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. 5 PERMIT VALIOATI N
ADDRESS � SPECIAL CIRCUIT
APPLICANT'S / •
ZIP EMP.METER OR POLE INS. 15.00 e//� /��
ADDRESS MOTORS SEE FEE SCH. (((
�j
SERVICE CHANGE 10.00 / d�
I woo LICENSEDCON'I'RACfORS DECLARATION � -
U,U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G<d (commencing with Section 7000)of Division 3 of the Business and a DG ELECT. PLG. MECH.
r y i Professions Code,and my license is in full force and effect. ❑ ❑ 1:1o i m W License Class Lie.Number._
Dutc Contractor
a x s IL'DINGjPERM1T'
¢ s, w.� OWNER-BUILDER DECLARATION �'`'7 '�"INFORMATION
wDA MISC.— REFER TO ORD — L'
a- Elm I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
LL0 ¢ Low for the following season.(Sec. uiresa,Businessand Professions PERMIT ISSUANCE 6,00
fw>f Code:Any molish county which structesxp riot ttoconsuance,alset,o
—V/ O
2 ¢O improve,demolish,or repair any structure,prior ID its issuance,also ELED.CONTR. LIC.NO.
ELEC.
al isO ac requires the applicant for such permit to fila a signed statement that TOTAL / PEERaMIT TO '
' to$'s he is licensed pursuant to the provisions of the Contractors License 5 ��[HT
'i
Law(Chapter 9(commencingwrth Section 7000)of Division 3 oftli•
io Business and Professions Code)or that he is exempt therefrom and OTaY. i 0, ':, PLUMBING,PERMIT
¢F m the basis for the alleged exemption.Any violation of Section 7031.5 .,*-°' s STORIES ppTYY/P--E CONSTR.
a ; _ by any applicant for a permit subjects applicant penalty h ALTER-DRAIN&VENT-WATER (EA.) 4.00 TG GCI C )tie —
, of not more than five hundred dollars(55000.):
❑ I,as owner of the property.or my employces 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
int tided or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. .4.00 -
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 . SO FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,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 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON Pe Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting will,
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.) 1.00contrathe
Co is Contractor's
such License
projects with a iontructosls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Iha Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER WIVENT 4.00
mason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00 I
I hereby affirm that I have a certificate cdcoment to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy shereof(Sec.3800,Lab.CJ. '
Policy No. Company
C) ❑ Cerlifiedcopy'lsherabyfurnished. FIRESPRINK ENERGY T-24
Z_ Z ❑ Certified copy is Filed with she city inspeclion division. MISC.- REFER TO ORD. y� N� yE] N�
O Applicant
Fy CIi RTIPICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� —
LU �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Yo . N❑ Y [3 No
CL 0 (This section need not he completed if the permit is for one TOTAL
:3 Z hundred dollars(5100)or less.) %r '
fJ 0 1 certify that in the performance of the work for which this per 'A +i'Y .rtl•rs8. s EEA UMMARY
STY. MECHANICAL. RMIT FEE
IL f mit is Issued,I shall not employ any person in any manner So as to I ! T
O L) has.om j Warkcrs' ns.li s aliform. " BUILDING o
Date pelican ALTER OR ADD TO MECH. 4.00 a
} N NOT CE TO AIR ICAN'f: I ,after ma: g this ifcate of 1 x
2 emplion.you should become subject to the Work ri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE / IP
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AMC.F.M.) 3.00 t -\
CONSTRUCTION LENDING AGIiNCY AIR HANDLING UNIT(OVER 110000QRM.) 5.00 SEISMIC.FEE 2J V
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 HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I ceitify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PWMBING
BOILffi•COMP(3 H.P.Or 100,000 B.T.U.) 4.00
ordinances and state laws relating to building construction, and
hereby,authorize representatives of this city to enter upon.llie BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
slave-manlioncl properly 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 CONST.TAX -
may in any way accrue ag 'nsl said City in Consequence of the PERMIT ISSUANCE 3.00
grant' fthis permit MECH.CONT. LIC.NO.17 MECH.
TOTAL r
TOTALS:
ature of Virgri ea n/C clot Uase
OFFICE COPY