2484 (2) PPLICANT TO FILL IN INFORMATION WITHIN REP'LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FI ATION PERMIT NUMBER
JtBUILDINGAPPLICATION &PERMIT A 8 Y
Q /�
ADDR55 �' `F
PDDR
- �b "(,r-� --AtJ BUILDING -'ELECTRICAL-PLUMBING -MECHANICAL 1
OwMER'S - - PLAN CHECK VALIDATION
ME '.DTV. ELECTRIC PERMIT 'FEE
PHONE
CONTRACTORS
E UTLETS-SWITCHES-RECEP 5.00/1.00S
I) L�Qr L�tJ�- uc.No, 1 `Z. LIGHTING FIXTURES 5.00/1.00 _ .
CONTRACTOR Spp LIANCES-'RESIDENTIAL 4.00 -
A ORE C
• G� a� J. PHONE, 4. 13 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO."
OR
ENGINEER
Sec,NO SIGNS TRANS.'. 3.00 -
ARCH)OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00Ic
•ZIP TEMP.METER OR POLE INS. 15.00
FooR[ANT5 N^� MOTORS SEE FEE SCH.
PL7,.jy ZC __ SERVICE CHANGE
o o LICHNSEU CONTRACTORS DECLARATION
< U I•j 1 hereby affirm that I ani licensed under-.....vision s of Chupter 1) 'i� ISSUANCE DATE
H z w fcommencinN with Section 7000)of Division 3 of the Business and
<y BLDG. ELECT. PLG. MECH.
o z Professions Cod td my license is in full fore` - 4•e� ❑
z o H - License lass Lic.Number l - ❑
9 m r Date Comractor �.��7�
¢ m f BUILDING PERMIT
¢ ¢ LL OWNER-BUILDI;RDECLARKITON INFORMATION
a oR.. MISC.- REFER TO ORD
w g LL H I hereby affirm that Iain exempt from the Contractois License H. VALUATION $/FT.
u04 Law for the followingreason.(Sec.7031.5,business and ProfessionsPERMIT ISSUANCE 6.00
E °sof Code:Any city orcounty which requires a permit to construct,alter,
¢ ¢ <o improve,demolish,or repair any structure;prior to its issuance,also ELEC.CONTR_ LIC,N0. ELEC.
¢ 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 Contractor's License � � `•
r r Law(Chapter 9(oommeneing with Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and QTY. -PLUMBING PERMIT FEE r
.¢ H o the basis for tlm alleged exemption.Any violation of Section 7031.5 ^ STORIES TYPE CONSTR.
n 3� by any applicant for a permit subjects the uppliclun to civil pin ulty ALTER-DRAIN&VENT-WATER IEA.) 4.OD
of not more than five hundred dollars(8500).): _
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Oce.GROUP RES.UNITS
their sole compensation,will do the work,and the stnature is not
intended or offered-for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR AREA TOTALACREAGE
himselforthrough [itsow oemployees, le.If,however,
thiboildie GAS-EA.SYSTEM-I I NC,4 OUTLETS 4,00
Improve-
ments are not intended or Offered for sale.If,ed that S the mp ove-
'orimprovement is sold 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 lie did not build or im- RES - IND CON .PB One,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ I,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law dies not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 `-
contracts for such projects with a contractors)licensed pursuant m -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA..200ft/8.00 TRACT NO. PARCEL No.
❑ I am exempt under Sec. ,B.&P.C.for this
WATER HEATER W/VENT 4.00
reason
Dace _ Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00 ! '
I-hereby uttirm that I have it certificate of consent to self-Insure, P• ZONING
ora evoificme of Workers'Compensation [lis ice,or u certified ENG.SITE NO,
Popy licy No. (Sec. Co pa y.{n29Pi
Policy ere Company.
O ❑ Certified copy is hereby fO - FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is in pection division.
MISC.- REFER TO ORD;
o APPhCamt Y ❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE - 6.00
D: CER 1'1171. EOP EXEMPTION PR ORKIiRS' - - - FLOOD ZONE. A.L.UC.
W . COMPENSATION INSURANCE PLG.CONTR. LIC:N0. pip, L df.0
0. 0 (This Section need not:be completed if the pant it is for one TOTAL o Y E] ❑ N
N❑ Y' ❑
hundred dollars($100)or less.)
L) O I certify that in the performance ofthe work for which This per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL ♦- mit is issued,I shall not employ any person in any manner so as to
OW become suhjem)o the Workers'Compensation Laws of California, BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
} y NOTICE TO APPLICANT':'If,after making this Certificate of Ex.
H Z emptlon,you should become subject to the Workers'Compensation APPLIANCE4.00 PLAN CHECK
provisions of 1the Labor Cade, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING,UNIT(TO 10000C.F.M.) 3.00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10000C.EM.15.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perfonnanc f the work for which this permit is issued(Sec. MICROFILM '
3097,Civ.C.). }t^�' \� - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Namey-.r��12'- ' ""� '�'
HEATING UNIT(OVER 100,000 B.T.U.17.50
Lender's ABdres S-F,..-�-'-^z-a--. � � ELE CTOIC o2�
I certify that I have road this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county BOILER-COMPI(3 H.P.or 100,0008.T.U.) 4.00 PLUMBING
o•dinances and state laws retailing to building Cons[raction, Hull -
peby utItl,.,i,e representatives of this city tO enter upon the BOILER-COMP [OVa!100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for in on p posros. -
(We) agree to save, Inde rat ep Itunulcss the City of 'MISC.- REFER TO ORD. -
Cupertino against mint g c car and expenses which PERMIT ISSUANCE 3.00 CONST,TAX
may-
in'any to t Ci y i consequence of the
grantin Is MECH.CONT. LIC,NO, MECH,
TOTAL TOTAL J
Sigrlatu 01'Ap turn
Date
. .. .
3
OFFICE COPY s ,