3838 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ILDQ Q
ADOREss U lJ v
ING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
N
DTV. ELECTRIC PERMIT FEE
PHONE 2S 7-
NAME acroRs OUTLETS-SW'TC
HES-RECEP 5.00/1.00
K 1 IA)W uC,NO. q7Z LIGHTING FIXTURES 5.00/1.00
roNrRa roll's APPLIANCES-RESIDENTIAL 4.00
aooREss
VHDNE -Q1 PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P,Q NO,
ENGINEER
LIC.No. SIGNS TRANS. 3.00
noo ees ENG' SPECIAL CIRCUIT 5,QQ PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
APPLI
BOORDDREss MOTORS SEE FEE SCH. S
SERVICE CHANGE 10.00 I /f✓3
,00 LICIiNS1iD CONTRACTORS DECLARATION
G
on I hereby affirm that 1 am licensed under provisions of Chaplet 0 ISSUANCE DATE
(cont mencing with Section 7000)of Di hien 3 of tie Business anA BLDG. ELECT. PLG. MECH.
0 i Professions Code, d��yyyy license
"In
sN full fur ❑ ❑ ❑ ❑
z o m - Lice
CP
{s A hie.Number
E H r Dau_ -Sof.-44 COmfaCtOr
ss m BUILDING PERMIT
a o c U OWNER-BUILDF;R DECLARATION INFORMATION
w3 H 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
F LL o j Law for the following reason,(Sec.7031,5.Business and Professions PERMIT ISSUANCE vALUAT10N $/FT.
Code:Any city or county which requiresa permit to construct.aper. 6.00
ic ¢Q improve,demolish,or repair any structure,prior ID its issuance,also ELEC.CONTE. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL
w $m he is licensed pursuant to the provisions of the Contractors License I ' PERMIT TO
Hza Law.(Chapter 9(creamencingwith Section 7000)of Division 3 of the A
3 ¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged excmptlun,Any vinlitti,en of Section 7031.5 STORIES TYPE CONSTR.
d ; " by any applicant for n permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
proof more than five hundred dollars(S500).):
❑ 1.as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE- 2.00 OCC.GROUP REs.UNITS
their sole compensation,will do the work,and the strucuve is not
intended or oltered for vale (Seca 7044, Bussocss and Poflessloos DRAINS-FLOOR,ROOF,AREA.CONIC. 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 employees,provided that such improve-
menis arenotlmended or offered for sale 11,however.IIIc huddling GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or inmmvcmcnl is soW within are year of Com Plction, the owner-
, I builder will have the burden of proving that he did not build or inn- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Do,.,
O 1,as owner of the property,am exclusively'contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct it,, project(Seca 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO,
and Prolusions Code:The Contractors License Law docs riot apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contmels forsueh projects witlt a cmuract(ids)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑reason lam exenmt under Sec .B.ACC.til this WATER HEATER W/VENT
4.00
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK RRS'COSIPFNSAiION DECLARAT'1ON WATER TREATING EQUIP. 4.00 -
I hereby affirm that I have a certilielde of consent to sell'-insure. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereofji co, 3 00,Lab.C.).L !1
Policy . . Company GFf+�ZCR-tS-G .
0 ❑❑/(eraDlmd copy is hereby furnisled.
Z IM Certified py fide w!;�o the inspection di "oat. FIRESPRINK ENERGY L24
Applicant- p-/f?I� _ UI MISC- REFER TO ORD.
Z 1�1�---f- rla�G-- Y ❑ N❑ Y ❑ N❑
~ ran PERMIT ISSUANCE 6.00
LU
CIi RTIIlGO!oiONHATI N INSURONI WORKERS FLOOD ZONE A.L.U.C.
W CO\IPIiNSATION INSURANCE PLG.CONTE. LIC.NO. ^I PLG, Y N❑ v❑ N❑
CL O (Phis section need not be completed if the permit is for one P
TOTAL
:D Z hundred dollars(5100)or less.)
U O 1 certify that in the perfonntmce nl'the work I'or which this per- GTY. MECHAN �,pE�} T FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner xo as to nF'1' f M t(J,8
O W become subject to the Workers'Compensation Laws of California. L.V i
Datc Applicant BUILDING
CL ALTER OR ADD TO MECH' 4.00
} N NOTICE 'TO APPLICANT: If,after making this Certificate of Ex-
Fz minion.you should become subject to the Worker,'Compos,mion APPLIANCEUlty of pet .00 PLAN CHECK{
provisions of the Labor Code, yon must forthwith comply with FEE i'
U such provisions or this permit shall he dcenied revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is .,construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued IScc, MICROFILM
3097,Civ C.1. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Nam
e HEATING UNIT(OVER 100,000 B.T.U.)7.50
lender's bar ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 '
info....inion is correct. i agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this oily v, enter ..m
bovon the 801 LER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL V
u-muntlnncd property rtytY�l nr inspection purposes, _
(we) agree to save, indemnify and keep harmless the City,of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costsand expenses which CONST.TAX
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE -3.00
gran tit of this pennot MECH.CONT. LIC,NO. MECH. `�-
' it --�• J TOTAL 7 TOTAL
Signature ofJ�Adpplilca�n�t/C ntnnc«t Dale I \ l�. O q7
OFFICE COPY