3588 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN O LY
PERM UMBER
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BUILDING PROJECT IDENTI FICATION APPLICATION & PERMIT 3588
P OREaS' '
BUILDING -ELECTRICAL-PLUMBING -MECHANICA
LAN
RCHECK VALIDATION
AVE
TY. ELECTRIC PERMIT FEE
ON
N°:1 /�- �, UTLETS-SWITCHES-RECEP 5.00/1.00
IC) sec. LIGHTING FIXTURES 5.00/1.00
AONREACTORE PPLIANCES-RESIDENTIAL 4.00
MHO PANELS 5.00 DATE OF APPLICATION
pq HITECL � ' SIGNS 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00 -
ADDRRESS E"G SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AUDIES ICANrs
AODRMOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 �I
w o o LICENSED CONTRACTORS DECLARATION
- 0 v I hereby ef6on (bat I um licensed undo,prni siuns of Chapter 9 ISSUANCE DATE
N s. (commencing with Section 7000)of Division 3 of the Business mW
¢ BLDG. ELECT. PLG. MECH.
r o z Professions is in full for f'
z o u, - License ClassLin.Numbmer
y- Dale + Contrncr_
Qy C J
¢
OWNER-BUILDER DECLARATION BUILDING PERMIT
A o a INFORMATION
X ; LL H I hereby affirm (hal I am esempl from the Contractor's License MISC.- REFER TO ORD
F LL o J Law for the following reason.(Sec.7031.5,Buslnessxnd Professions PERMIT ISSUANCE VALUATION 3/FT.
Code Any city or county which re.pl it s e penllit 10 construct.aIle,. 6.00
¢ � ) ELEC.CONTR. LIG NO.
¢ improve.demolish,or repair any structurt,prior to its issuancq also ELEC.
¢ requires the applicant for Such permit to fle a signed s atemenl that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractors License
ca z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
1 E o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F othe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ro
a; _ by any applicant for a Pemtit,eohjects the upplicam to a civil penalty ALTER-DRAIN8, VENT-WATER IEA) 4,00
of nut more than five hundred do0).1
llars,150 :
❑ 1,as owner of the proNfly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DEC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code 1'hr Colaruclois License Law Jots not apply lu on owner of
properly who builds or improve thereon,and who dues such work FIXTURES-PER TRAP 4.00 MFT.FLOORAREA TOTALACREAGE
himself or through his own employees.Provided that such improvc-
menls am met intended or offered per sed,If,however.the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or Imprmamenl 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 Hot he did not build or'in
RES IND GNG PB Other
Prove
for Purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑.
❑ 1,as owner of the pro Pert y,wn exclusively contracting with
licensed contractors to construct the proper(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law vows not apply
to an owner o1'property who builds or improves thereon.end who LAWN SPRINKLERS-OVER 5(EA.) _1 m
contracts for such projects with a commururts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ixmexcmplunder See. ,B.&P.C.forlhis WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORAERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 love a Ceriticaro of consent In self-insure. ZONING
orrpa certificate off,yW�orker�s'Compensation insurance.or a certified ENG.SITE NO.
C fie r�`XGt�h1 Y1--7"I
Q ❑ Certified copy is hereby furnish¢ FIRE SPRINK ENERGY T 24
z O s�tenifmd fled with c ly tion Jivisiun. MISC.- REFER TO ORD. v N v N
CHR'F1171CA'117017 EXEMPTION 17ROb1 RKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COAIPENSATION'INSURANCE PLG.CONTE. LIC NO. PLG. //��''\\
1 a (This section need not he completed if the permit is liar uI TOTAL 0$CC Y❑ -F] Y❑ N❑
::) Z hundred dollars IS 100)or Imi
U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL
I. mit is issued, I shall not employ any person in any manner s0 as to
O Q become subject In the Workers'Com Pensation Laws of California.
6 par° Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
)--' 2 empHon,you should become subject In the Workers'Compcnwliun APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith 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 10,000C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
thr
Elie performance of the work for which this permit is isumd(Sec. ,MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NamAddress
H EATI N G UNIT(O V E R 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and slate that the aboveVENTILATION FAN (SINGLE) 3.00
information is curca. 1 agree ser comply with all city end county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of (his city to enter upon the
above-mentioned pmperty for inspection purposes. BOILER-COMP (0.,100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to It, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino oleins, liabilities,judgments, costs and es Penses which CONST.TAX
may i Ry we ace against said City in consequence of the PERMIT ISSUANCE 3.00
gm ng thi or ti - MECTCONT. LIC.NO. MECH,
TOTAL TOTAL
Sib rent "Ideant/Contractor Dec
OFFICE COPY