3138 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFIC PERM NUMBER
Im LDING APPLICATION 8, PE T 313 8
ADDRESS
' //S / DFK aySH It jjK BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME / CITY. ELECTRIC PERMIT FEE
CLA a.✓PHGNE2sSo3
CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
uc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
A p DRESS
PHONE PANELS - 5.00 DATE OF APPLICATION
ARCHITECT SIGN$ 6,00 PLAN CHECK FEE
OR
ENGINEER 3.00
uc.No. SIGNS TRANS.
ARCH,OR ENG. - 5.00 PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT
zm TEMP.-METER OR POLE INS. 15.00
AErs MOTORS SEE FEE SCH.
ADDRODRESSss
SERVICE CHANGE 10.00 C/I �/
o ¢ z G /
r
00 LICENSED CON'T'RACTORS DFCLARA'1'[ON
a u I hereby affirm that I an licensed under provisions of Chapter 9 ISSUANCE DATE
w G w (eommencing with Section 7000)of Division 3 of the Business and BLDG. ELEOT. PLG. MECH.
H mz Professions Code.and my license is in full force acid effect. Z Q ❑ ElElz o m - License Class LI[.Number
O 2 F Dote COnlmctor r
a Y f/N9 l I,/( r R o -F1 3 ^6,b BUILDING PERMIT
a, w u OWNER-BUILDER DECLARATION INFORMATION
wLL N I hereby affirm that 1 am exempt from the Contractor's Licenx• MISC.- REFER TO ORD
LLDa Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION 5/FT.
- Code:Any city or county which refpyimxo permit mconstract,Alec, Q C)
T ¢ o Huprove,denmlish,or repair any stricture,Priorto its'usuo^ce,also ELEC.CONTR. LIC.NO. ELEG
- 0 0 requires the applicant for such permit to file a signed statement that TOTAL PERMIT To
wm be is licensed pursuant to the provisions of the Contractor's License
r• z i
Law(Chapter 9(commencing with Section 7000)of Divisio^3oftire
PLUMBING PERMIT FEE
of Business and 1'rofessioms Code)or that Ile is exempt therefrom and QTY.
T o the bosis for tins alleged,seat prior.Any violation of Section 7031.$ STORIES TYPE CONSTR.
dam _ by any applicant fora Permit subjects the applicant to. I"]penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 P
of not more than five hundred chyars(SSOOT):
❑ 1,as owner of the property,or my employ's,,with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GRO P .RES.UNITS
their sole conspeosation,will do the work,and the structure is not
intended or offered for sole(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cmc:The Contractor's License Law does full apply m an owner of It of Cu ertin
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 employcrs,prosided that such improve- GAS-EA.SYSTEM-11INC.4 OUTLETS 4.00
arents are not intended or offered for sale IL however,the building
_ nr improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will lave the burden of proving that le did nut build of In_ m
RES IND CON PB Oar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
0 I,as owner of the property.any exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCELNO.-
and Professions Code:The Contractors License Law dies not apply
to an owner of property who bolds or Improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a Lontractons)licensed Pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/5.00 TgACT No. PARCEL NO.
ICL l ars exempt under Scc. .B.&P.C.Or this WATER HEATER W/VENT 4.00
reason
Dale1_/ ; eA ^rr WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMTENSA"UON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of runway to self-insure,
or a certificate of Workeri at
Compension Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Scc.3800,Lab.CJ.
Policy No, Company
O O Cetlt ficd copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 0 Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD. y❑ N❑ Y C:] IN
O Applicant
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� > CI?RTI FICATIi OP EXIiMI"PION PROM WO
LU COMI'I?NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ Y ❑ N❑
CL 0 (This section need nm be completed if_tire permit is for one - TOTAL
2 hundred dollars IS 100)or It..)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued, I shall not co,loy any Person in any mannersoif,to
U W become subject to the Workers'Cony rcnsution Laws of California. _
Dale APPlicay 1 ALTER OR ADD TO MECH, q-p0 BUILDING as�s7-
} h NOTICE."f0 APPLICANT': 11,after making this Certificate ul'I--s-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you frost forthwith Comply with- FEE
U such provisionsor this permit shall be decnmd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 �p
CONS'FRUCHON LIiNDING AGE'
NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE tl
1 hereby' affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work lift which this penult is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is comet, 1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building c^nxtruchi and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL .
\ above-mentioned property for inspection purposes.
OVP) agree to save, indemnify and keep harmless the Cityof MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
nym
mntin
ay in n w a'umc ugus Id City in c..... pence of the PERMIT ISSUANCE 3.00
IT a Ir - MECH.CONT. LIC.NO. MIC H.
TOTAL TOTAL a r
Signature af�mtrodor Date
OFFICE COPY