17812 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,- USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT 1781 t.7
A rRENG EN 1 �T G
A 2R0& 5S AVDE"S��� G1I BUILDING-ELECTRICAL-PLUMBING-MECHANICAL y
OwNER's ��Dp�l A five PLAN CHECK VALIDATION
NAME 1�✓"f_
CIT)�S r153 )(Ala'TY. ELECTRIC PERMIT FEE-
CONTRACTOR
EE- - -
PHONE
NAME coRs�iy,/A /i &V UTLETS-SWITCHES-RECEP 10.00/1.00
NAME .*i//'U
s� n/�rf Q LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRADDIPEcr �-i��/'� �' PPLIANCES-RESIDENTIAL 4.00
6DDRE55 ;,i'!/ -
PHONE PANELS 10.60 DATE OF APPLICATION
1AROgcHrrecr PANELS (OVER 200 AMP) 20,66 PLAN CHECK FEE P.C.H
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG,
SPECIALCIRCUIT 5,66 PERMIT VALIDATION
I' z EMP.METER OR POLE INS. 20.00
APPucANTS
S SEE FEE SCH. l_
ADDRESS
r ') R /I S C A GE 20.00 ,^,
woo LICENSED COMRACTORS Df:CLAR 10c
H =w 1 hereby fr,.that 1 am bcenmd under prosii oyy((Qq1.�{1�pier 9V _ ,y ISSUANCE DATE
Q (commencing with Section 7000)of Divisippn 3 of IFJMI{im'ss sand B DG. ELECT. PLG. MECH.
r N z Professions Code,and my licenu ix in full tiswe.aad effect. CII
0 0 rn - License ClassLic.Number t 1'
yr w Date Contractor 1 111
a m .BUILDING PERMIT
¢ ¢ w sf OWNER-BUILDER DECLARATION
x u INFORMATION
A N I hereby'affirm that I am exempt from the Contractor's License MI$C.- 1 P R 70 RD
LOJ Law for the followingIng VALUATION $/FT.
reason. 7031.5.Businw and Professions PERMIT ISSUANCE A0:00 A
Cale:Any city orcounty which requires a permit to construct,alter.
¢
¢ o improve,domolish,or repair any structure,prior to its issuance,also ELEC.CONTE. ,LIC.NO, ELEC. sn bfJ l/ V
O u requires the applicant for such permit to file a signed statement that TOTAL L�--1 P
whe is Iiernsed pursuant to the provisions of the Contractor's License ERMIT TO
r z a Luw(Chapter 9(commereing with Scow.7000)of Division 3 Frill,
4 0 BILo ess and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE SFDW
¢ I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TV PE CONSTR.
by any applicant for a permit subjects the applicant to a civil P rally ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollars($500).): -��
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not '
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code The Contractor's License Law does not apply to an owner of ply
property who builds m improves Iher,Fn,and who docs such work F IXTUR ES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. f
menti are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 I/I Qs/l /�7\
or improvenlonf is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 `t`/L t.v
builder will have the burden of proving that he did not build or ins- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Omer
❑ I,as owner of the property, on e,elmasely contacting with 0 0 O Q
licensed mnvactors to construct the project(Sec.7044,Bluffness LAWN SPRINKLERS-1 INC,S V.B. 6.00 gSSESSORS PARCEL No.
and Professions Code:The Contractor's License Lawdoes not apply
to an owner of property who builds of improves(hereon,and who LAWN SPRINKLERS,-OVER 5(EA.) , 1.00
contracts for such projects with a contracton.$)licensed pursuant m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See B:&P.C.ter this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE - ACC.FILE NO.
WORKERS'(70.NIPENSA'TON DECLARATION WATER TREATING EQUIP. . 5.00 _
I hereby affirm that I have a ecrfificate of consent to self-insure, rT ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a nerflfed 3'7
copy thereof f Sec.3800,Lah.C.).
Policy Na Co y
0 ❑ Cert311ed copy' creM1any FurnisheJ, FIRE SPRINK ENERGY TQO
Z Z ❑ .'Rifted m is filed wit he y inspect division.
O MISC.- REFER TO ORD.
APPIi ant v N� v N�
CCPERMIT ISSUANCE 3A'OB IR FLOOD ZONE A.L.0 c.
K 4a : EICA'fIi OF C li%ENPI'ION FROM W'O KF-RS'
L > COMPENSATIONS INSURANC17 PLG.CONTE. LIC.NO. PLG.
CIL O (This section roved not be completed if the permit is for one TOTAL O� Y❑ IN Y❑ N�
Z hundred dollars(5100)orlcsa.) -
0 O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- it is issued, I shall not employ any person in any manner ul as to
0 W become subject to the Worker'Compensation Laws of Culifornia.
y Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT. If,after making this Cerld tate of E.-
FZ empron,you should become subject to the WorkedCompensation APPLIANCE 5.00 PLAN CHECK _
provisions of the Labor Code, you nasiforthwithcomply with FEE '-
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 .F.M.) 6.00 SEISMIC FEE 8J3
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued ISec. MICROFILM
3097.Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Nam. HEATING UNIT 100,000 B.T.U.)9.50 ACILender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
® information is correct.1 agree to comply with al` m
city'and county BOIL FR-COW(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING �q d
ordinances and .fate laws relating to building construction, and D�
hereby authorize repreuntafives of this city to enter upon the BOILER-COMP IOser 100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned progeny for inspection purposes. .!
(We) agree to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD. -��
Cupertino ages' Sj/liebilitics�judgmcnts, vests and expenus which PERMIT ISSUANCE 46:66 (/� CONST.TAX
may in an• ly accrue a in mid Cil in rots, Bence f[hc
• anting m Perm t. / MECH.CONT. LIC.NO. MECH.
7 TOTAL D15 TOTAL [f
q`1 I
tort of Applicant/Contractor Uat Dq /
OFFICE COPY