3976 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
'BUILDING PROJECT IDENTI FICATION - APPLICATION & PERMIT 3976
euuomc
ADDRESS ��
Ifq� VjnloBUILDING'- ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S
P AN CHECK VALIDATION
NAME A TY. ELECTRIC PERMIT FEE
Milk jiPro.E ITWI
ilnree ACToe UTLETS-SWITCHES-RECEP 5.00/1.00
uc.No. LIGHTING FIXTURES 5.00/1.00
CON
TRACTORS
DRESTRA<roRs
APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDR'E55 ENO ISPECIALCIRCUIT 5.00 PERfA���r1rDATION
ZIP TEMP.METER OR POLE INS. 15.00 FFpp YV/
APPucANT$ -
Ao°REss MOTORS SEE FEE SCH'.
FSu
SERVICE CHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION City Of.CUQe
dine
a I hereby affirm Ileal I ant licensed under provisions of Chapter 9 Y •ISSUANCE DATE
(connnenang with Section 7000)of Division 3 of the Business and a
F h z Prolesstons Codc,and my license is in full force B ELECT. PLG. MECH.
e and effect. 1 h i .(. ❑ ❑ ❑
z O m - License Clas Lie.Number
Q F o Date Contractor '
a s, 2 UILDING PERMIT
- a OWNBR-BUILDER DECLARATION
0A INFORMATION
wS LL H 1 hereby affirm that I am exempt from the Contractor's Liccnu. MISC.- REFER TO ORD
cat Ww'for the following,,.,,, 7031.5.Buelnexsand Professions VALUATION S/FT.
_ PERMIT ISSUANCE 8,00
Code Any city or county which requirese Permit to construct,alter,
Qre 4 o improve,Demolish,or repair any structure,Prior In i¢issuance,cele ELEC.CONTR. C.N0. ELEC.
O u raluires the applicant for such permit to IIIc a signed statement that TOTAL PER
to he is licensed pursuant to the provisions of the Contrtclor's Licrnw
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe DDI-
1 Eo Business and Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE
R E_ the basis for the alleged exemption.Any Vmlatmu of Section 7031.5 STORIES TYPE CO STR.caby my ,
n , ofeHImorethanFiveant for ,,Emit dollarsyheapph 00.): ammacivilpenally ALTER-DRAIN -WATER (EA.) 4.00 /��iIL�6/1//1-1(
of nny more than Five hundred dollars 6500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RE9.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for .If (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sa FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employs.provided that Such improve-
mentsare not intended oroffered for SalalLhowovorl 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(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsale.), INDUSTRIAL WASTE INTER: 2pp0 INA CON PB Cm.,
El as owner of thir e Property,aexclmi -
Jely contracting with
licettsed.comEl El ED 1:1ractors to construct the project(Sec. 7044,BUSIOFS" LAWN SPRINKLERS-1 INC 5 V.B. 5.00 - ASSESSOR SPARC EL NO.
and Professions Coca:The Contmaor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.o0
contracts for such projects with a eamtracoms)licensed pursuant to t
the Contractor's L SEWER-SANITARY-STORM EA.200ft/8.00
TRACT No. PARCEL No.
❑ cm Suer, c ,If WATER HEATER W/VENT 4,00
rcawn APO
Date Owner WATER SYSTEM 4.00 ACC.OATE -ACC.FILE NO.
-woRKERS'CO 11'IiNSA'I'ION DEC.LARA'I'ION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 hash a certificide of consent to self-inssue,
or a Certificate of Workers'Compensation Insurance,or a certified I ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lah.C.l. .
Policy No. Company -
O ❑ Cenified copy is hereby fraud hed.
FIRE SPRINK ENERGY T2
z OZ ❑ CenificJ copy is fled with the city inspection division. MISC.- REFER TO ORD. v ❑ N❑ Y [:J N❑
Applicant
W~ rnPERMIT ISSUANCE
> CERTII'ICATE COIIPOLNSATION INSURANCEXEMPTION FROMMORKERS' PLG.CONTR. LIC.NO, PLG B00 FLOOD ZONE A.L.U.C.
C OThis Section need not be completed if the permit is for one TOTAL Y[:] N❑ Y❑ N❑
Z hundred fullare(5100)or less.)
U O 1 certify that in the performance of the work for which this par- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit Is issued,1 shall not cnnploy eny person in any manner so as to
O w become Subject to the W'orkeri Compensation Laws of California
Dare Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 3 G
} 5a NONCE '1'O APPLICANT: If,after making this Certificate of Ex- o
? 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
U "loll provisions or this permshk
it all be dermad revoked. AIR HANDLING UNIT(TO 10=rC_F.M) 3-00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNTT(OVER 10)000C.F.M,) 5.00 SEISMIC FEE J�
1 hereby uIrrm that there is aan,fuation lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,CH,.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have mad this application and state that the above VENTILATION FAN (SINGLE) 3.00
0 inom nmion Is comet. I igrcc to comply with all city ,all county BOILER-OOAT(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stats: laws relating to building constructure. and
hereby authorise representatives of this city to enter upon the BAILER-COMP Over 100000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. , MECHANICAL
(We) agree 10 save, indemnify and keep barmlas the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and experts.which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way seem, against said City in conwyuence of the
ing of this pc n MECH.CONT. LIC.NO. MECH.
3-Signa ore o'A -ant/Cont rdul°r tole TOTAL TOTAL
OFFICE COPY