5986 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT]FICATION PERMIT NUMBER
BUILDIND APPLICATION & PERMIT
y� ADDRESS
R YI ¢. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 5986
OWNER'S -
NAME
OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION.
101 1 Lk li't
�ob�l , RDNE s 9
CONTRACTORS
NAME t L' act OUTLETS-SWITCHES-RECEP5.00/1.00
Tr41 """t / ci/7-f NO LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4,00
ADD.Ess
n
AR� /1/QU (.�� PRONE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR
ADDRESS ENG. 1
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
AMOTORS . SEE FEE SCH.
ADDRESSDDRESS
SERVICE CHANGE 10.00
Dat
F o o LICENS that I. I'RA CTed R DECLARATION
av I hereby uffinn that I am licensed msder provisions of Chapter 9
2 - I ISSUANCE DATE
kaon...voting with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.. MECH.
r y i Professions Cod license a in lull fort" ❑ ❑ ❑ ❑
2 o m,- Limen'•Clas a srb,er Number
9 y t W- bate - Comtm cror f/ f-x 9 ( /Z e 2 e e.F 9/f,
H
s w a OWNER-RUILDER DE ARATION $$YILDING PERMIT
woar NANFORMATION
; I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a-O j Law I..the following reason.(Sec.7031.5,Business and Professions V ALUAT fy $/FT.
L - PERMIT ISSUANCE 6.00 0
P a, 2 Cade:Any cityor coo my whiny structure,
prior
tloconsuanLaheq
a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.rv0. ELEC.
u c, requires the applicant for such permit to file a signed statement that TOTAL
w m Ise is licensed pursuant to the provisions of the Contractor's License PE O�?r
F i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe aC.V �WV
E i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE d~
I- o the basis for the alleged exemption.Any violation of Section 7031.5 --U�RIES TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.14.00
of not more than five hundred dollars(my em: co/-1/a, �f 6,
❑ 1,as owner of the property,or my employees with wageset BACK FLOW PROTECT.DEVICE l:
their sole compensation,will do the work.and the structure is not 2.00 OCC.GPO RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'fire h Contractor's s License Law docs not apply to an owner of
himself who builds or improves yeomen,and who docs such work FIXTURES-PER TRAP 4.00 $0.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
menImprovement
or within
on year o 11,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is held within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build m im-
provefor
asowneeofsalc.). INDUSTRIAL WASTE INTER. RES IND El Pe Omer
❑ I,as owner of the property.am exclusively contracting with 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and profession,Code:The Contractor's License Law docs rel apply
to air owner of properly who builds or improves thereon,and who LAWN SPRINKLERS'-OVER 5(EA.) 1.00
contracts for such projects with a contraclons)licensed falomant to
ore Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCELNO.
n O 1 am exempt under Sec. ,B.&I'.C.for this WATER HEATER W/VENT 4.00
owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WORK F,RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure,
or a Certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thersof(Sec.3800.Lab.C.L
Policy No. Company
O ❑ Cerliticd copy is hereby furnished.
Z,Z O FIRE SPRINK ENERGVT-
Certified copy is tiled with the city inspection division. 74
F O J Applicant MISC.- - REFER TO ORD. Y❑ N[:] Y 0 NO
CC W CE RTI FICATF-OF-EX EM PTION FROM WORK Ii RS' PERMIT ISSUANCE 6.00 FLOOD ZONE
LL COMPENSATION INSURANCE PLO.CONTR_.
d ❑ ('Phis section need not be Completed if the permit is fill one ITOTAL Y N❑ Y ❑ N
� 2 r hundmA A011ars(81001 or less.) .
U O 1 certify that in the performance of lire work for which thiser- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall mol employ a person in any an r so s to
bcco41y s c the Workers'C cnsation
BE Dalt=7= Annlicanl ALTER OR ADD TO MECH- 4.00 BUILDING �'/
W NOTICE TO A 1'LICANT: Iter makiJy this Cerlifican-of Ex-
F Z emptier,you shaulJ hemome object to the Workers'Compensulion APPLIANCE 4.00 PLAN CHECK
proA0
visions of the Labor Code, You must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 100C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER10=C.F M.) 5.00 SEISMIC FEE S6
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's'Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and Courtly PLUMBING
molmances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter ,on
the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree tD save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE CONST.TAX
in in any way accrue agai ssI and City in consequence of the 3.00
g ing e f this permit. ��y q MECH.CONT. LIC.NO. - MECH.
. - 116;z� / ^ .7- TOTAL
ignalur Applicant/Contractor Date I I
.-
TOTAL I
OFFICE COPY