5030 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN.ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT O 0
ADDRESS v
I � v6�/'E j•'K-+'�� BUILDINGELECTRICAL-PLUMBING -MECHANICAL 5
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
PHONE II
CDNTRACTOHSUTLETS
6 -SWITCHES-RECEP 5.00/1.00
7weva,ar� ,slNpa,16 &v IMc.
uC.NO. LIGHTING FIXTURES 5.00/1.00
r-ONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADim Est
it,7-149 IM PHONI21� PANELS 5.00 DATEOF APPLICATION
ARCHITECTOR SIGNS 6,00 PLAN CHECK FEE P,C.NO,
ENGINEER
LC.No. SIGNS TRANS. 3.00
ADDRESS E.G. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 P
APPLICANTS
MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 J
C 0 0 _ y LICENSED CONTRACTORS UECIA RATION
a v 1 hereby affirm that I am Iiecro wd under provisions of Chapter 9 g��
(commencing with Section 7000)of Division 3 of the Business and
G y L ELECT. PLG. MECH.
O t a Professions Co,yf,a y license is N ful�AIIO
a o v'Z - License Class Co Contract
El
O r w Dale��J�.liContract OBUILDING PERMIT
OWNIiR-BUILDERDELINFORMATION
wu I hereby affirm that I am exempt from the Contractor',License. 'MISC.- REFER TO ORD
o j Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6 VALUATION 5/FT.
Code:Any city or county which requires a permit to construct,allet.
rta, < p improve,demolish,or repair my structure,prior to its iaumuec,al.w ELEC.CONTR. LIC.NO. ELEG
w- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Commelor's License ��
Hai Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
the bass for the alleged a xemption.Any violation.1 Section 7031.5 STORIES TYPE CONSTR.
n ; by any applicant for a permit subhouts the applicant to a civil penalty
of not more than five hundred dollars 0500t): ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ 1,as owner of We properly,Or my eggmloyces with wages is - BACK F LOW PROTECT. DEVICE 2.00 CC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or offered-for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Co' ':
'rhe Contractors License law does not apply to an owner of _
property who builds or improses thereon,and who does such work FIXTURES-PER TRAP 4,00 SO.FT FLOOR AREA TOTAL ACREAGE
meats are oti intehrough nded
nw offered orale.If,ed that however.
the
impmvc GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
mems are me intended or offered for sale.If,however.the building
or improvement isb within one year Of completion,the owner GAS EASYSTEM OVER 4 (EA ) 1.00 BUILDING USE
builder will have thee harden of proving that he did not buil)or im - . - .
RES IND CO PB Orher
prove for purpose of ale)' , INDUSTRIAL WASTE INTER. 20.00 ❑
❑ L as owner of the property,run project ely
contracting ing with El
licensed contracture to construct the project(Sec. 7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSEB50 PARCEL NO. El
and
Professions Code:The Contractor's License Law does not apply
no tr owner of property who builds tr improves used o,and who LAWN SPRINKLERS-OVER 5 IEA'.1 1.00
contracts for such project with a cpntraclnrtsl license)punuanl no
the C. tractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TgACTN PARCEL No. '
0 tum exempt under See .B.&P.C.lin this WATER HEATER WNENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORK ERS'COMPENSAT']ON DECLARAT ION WATER TREATING EQUIP. 4.00 _
I hereby of Ilan that I have a cernifaate of consent to sch-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.Or a cenified
copy thereat(Sec.3800,Lab.C.L
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-242 Z ❑ Cerihcd copy is tiled with the city Inspection division. MISC.- REFER TO ORD.
F Q Applicant Y L] NE] Y E] NE]
� N CERT'IFICATCOPEXEMP1'ION PROM WORKERS. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.O.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y ry V N
CL O (This section need not be completed if the Permit u I'Dt one - - TOTAL
Z hundred dollars IS IOD)or leu)
.
U O 1 certify that in the performance of the work for which thi,Per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F iss
mit is med. I shasall not employ any person in any manner so to /�
O L, become subject m the Workers'Compenation laws of California.
S. Dmc ADPlica"1 ALTER OR ADD TO MECH. 4.00 BUILDING e�V
} to NOTICE. TO APPLICANT: If,after making this Cerlincane of
� Z
court
�
on,you should become subject to the Workers' APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE /J
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CEM.) 5.00 SEISMIC FEE e�
I hereby affirm that there is a consvua ion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
nhc performxn'e
of the work for- Ifich this permit is issued(Sec. MICROFILM
3097,Civ.C.). .I 1 �� HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Nai�A�i(.�f G( HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify mut 1 have read this application and swat that the above VENTILATION FAN (SINGLE) 3.00
e MI, Drmalion is correct. I agree m comply with all city and uOunly' PLUMBING
inances and state laws relating no building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
s hereby authorize representatives of this city to anter upon the
above mentioned property for inspection purposes. gOI LER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
- (We) agree to ave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against [ab ilitin,judgmen s, costs and expenus which PERMIT ISSUANCE 300 CONST.TAX
may in any way ecrve vgeinst City in consmocnec Of the
grant Df this iL MECH.CONT. LIC.NO. MECH.
_ TOTAL TOTAL
c o pp cant/ rac or Date
OFFICE COPY