5584 (2) APPLICANT TO FILL IN INFOR TION WITHIN RED LINES — USE BAA&POINT PEN ONLY
BLV LD1 NG PROJECT 1 DENTI FICATI PERMIT NUMBER
�C gp,LD,NG APPLICATION & PERM
ADDRESS -� �1I . BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 5584
ERyL'S��l�rh I C�L� l 1J PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
S7)2_ IGHTING FIXTURES 5.00/1.00
CONTRACTOR'S 3� PPLIANCES-RESIDENTIAL 4.00
AO cls
PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE .C.NO.
ERIn,S
Ea1�l SIGNS 6.00
ENGINEZL Wl"— I
LIC.NO. SIGNS TRANS. 3.00
ANCHOR ENG. SPECIAL CIRCUIT 5.0PERMIT VALIDATION
w Ess 0
rrEMP.METER OR POLE INS. 15.00 S
�Luc,,vrs /
womEs MOTORS SEE FEE SCH. ,
r—
SERVICE CHANGE 10.00
w o o LICIiNSED CONTRACTORS DECLARATION r
< v w prns I hereby affirm that I am licensed under ovisioof Chapter 9 ISSUANCE DATE
y (commencing with Section 71100)of Division 3 of the Bushes and
a N BLDG. ELECT. PLG. MECH.
F o Hofessfons Code,ws1 y license is in full furLLL f t
z o"Pj Lim�C}u /) Lit.'.Numbs
o F Umc l/ �Cantndor L�f(�
a` m 2 -j BUILDING PERMIT, F ,
¢ ¢ w a OWNii R-NUILUGR DIiCIA RATION
o O MISC.— REFER TO ORD INFORMATION v„ a
w ; LL 1 hershy affum that I am exempt from the Contnamr'a License sHIIiiii'VaLUATION
H u o g law for the following reason.(Sec.7031.5,Businessand Profesions PERMIT ISSUANCE 600 SIFT'
Code:Any city or county which reyuima permit to consiruNa,alter, �O
¢ ¢4 O improve,demolish,or repair any structure,prior to its i aounce,also ELEC.CONTR. LIC.NO. ELEC. L
o
ISrequires the applicant for such permit to 61ca signed statement that TOTAL
Le$ sw
m he u licensed purnt to the provisions of the Contractor's License PERMIT TO
F r Law(Chapter 9(commencing with Section 7000)of Division 3 of the
i i o Business and Professions Code)or tbm be is exempt therefrom and DTV. PLUMBING PERMIT `• �k/�NF
¢ H the basis for the alleged exemption.Any violation of Section 703 LCi lbf 5 S TYPE CONSTR.
e, i: by any applicant for a pencil subjects the applicant toil civil penally ALTER-DRAIN -WATER (EA.14.00
of not mom than five hundred dollars(55000.):
❑ 1,as owner of the prolwrty,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structum is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor'sLicense Law docs not apply to an owner of
Property who builds or improves thereon,and who dols such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve.
cnts arc not intended or offered for sale.l L however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is Sohl within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 700 BUILDING USE
builder will have the burden of proving that he did not build or ins. . . , RES IND CON PR Other
for purpoc of sale.). INDUSTRIAL WASTE INTER. 20,p0
0 1,as owner of the property,am exclusively contracting with 0 [:j ❑ ❑ ❑
licensed contractors m construct the project(Sec. 7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:I'he Contractor's License Law does not apply
10 an owner of property who holds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contnctags)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
0 l am exempt under Sec.—,If&P.C.for this WATERHEATER W/VENT
mason 4.00
Owner Uale WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKERS'COMPENSAfION DECLARATION WATER TREATING EQUIP. 4.00
I herehy affirm that I have a certificate of consent to w1binstuc, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Scc.3800.Lab CA �I�l->Policy No.No. Company_
0- Cl Ccrtif icd copy is I, by lurnizhcd. FIRE SPRINK ENERGY T 24
Z Z ❑ CerQ i filed with t(Y tion division. MISC.- REFER TO ORD.
Applicant Y ❑ NY ❑ N[]
CERTIFICATE OP fix EMPfI NFR0'M' KERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
L > COMPFNSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG. L Y � N�
0. 0 (this section need not be completed if the permit is for one TOTA
hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL. I— mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California. q v
0 a Date. Applicant ALTER OR ADD TO MECH. 4,p0 BUILDING 9 `�
} Go NO'I'ICF '10 APPLICAN`f If,afmr,making this Ccrtifcam of Ex-
= emption,you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U loch provisions or this permit shall he deemed revoked. - AIR HANDLING UNIT(TO 10=1C.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 a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work liar which this permit is issued(Sea. MICROFILM
3077,Civ.C.). HEATING UNIT(TO 700,000 B.T.U.) 4.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Names ELECTRIC
I certify that I have read this application and state that the ul eve VENTILATION FAN (SINGLE) 3.00
hoint. tion is correct. I agree to comply with all city and county PLUMBING
ordimincas and state laws ruling to building constmelion, and BOILEi-COA'P(3H.P.or100,000B.T.U.1 4.00
hereby authorise roprrtyfro ase, on city to enter upon the BOILER-COMP loss,(00,000 BTU)SEE FEE SCH. MECHANICAL
m"rmmentioned property for inspection purpoas.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against lisbiliti s,judgments, costs and expenses whicl, PERMIT ISSUANCE 3.00 CONST.TAX
may in any way -cruc against id CiI in con ue c of the
gnnling of this per tit. '\ IF MECH.CONT. LIC.NO. MECH.
s L
signup poli e., nater
TOTAL TOTAL 3
OFFICE COPY '