5993 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN-ONLY-
BU 11-6111,16 PROJECT IDENTIFICATION
EN ONLY-
BUILDINGPROJECTIDENTIFICATION w ' PERMIT NUMBER
BrILDING - APPLICATION & PERMIT'.
ADDRESS
_ _ _ _ 5993
� A BUILDING—ELECTRICAL—PLUMBING—MECHANICAL � '
O NER's - - • -- "" -- PLAN CHECK VALIDATION
' NAME DTV, ELECTRIC PERMIT FEE '
HONE
NO RacrORs OUTLETS-SWITCHES-RECEP 5.00/1.00 -
I � LIC.NO. 3 . LIGHTING FIXTURES 5.00/1.00
'1 r Z TRBCTOR'S - -
AO rt[ess7 PPLIANCES-RESIDENTIAL 4.00 ,
(. IPHONE f 3 PANELS 5.00 DATE OF APPLICATION
ARCHITECT ,PLAN CNECK FEE.
OR /C/+'IIr P.C.NO.SIGNS 6.00
' ENGINEER '
LIC.NO. SIGNS TRANS. ,3.00
ARCH OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT '5.00 -
zlv EMP.METER OR POLE INS. 15.00
APPLICANT'S �`
ADDRESS MOTORS SEE FEESCH. J
r SERVICE CHANGE 10.00 - r
2
0
0 u
' Foo LICENSED CONTRACTORS DECLARATION '• ��� 7v.
a U w, I hereby affirm that 1 am licensed under provisions of Chapter 9 - ISSUANCE DATE
¢n (commencing with Section]000)of Division 3 of the Business and OLOG. ELECT. PLG. MECH.
H w i Professions Code�aryJ Jqy license is in full force g9 fP ( - ❑ ❑ ❑ ❑
zO i m a Licens Class_[ �,5 /' Lic.Numbe Y. / l��q - Q ^
m H Date /b Contractor Fy�A L 9
¢_ w OWNER-BUILDER DECLARATION 1 BUILDING PERMIT
MISC.— REFER TO ORD INFORMATION
X 3 LL y I hereby affirm that 1 am exempt from the Contractor's License - VALUATION $/FT.
u O ¢ Law for the following reason.(Sec.703 L5,Business and Professions 6.00 :
- _ PERMIT ISSUANCE
m i Code'.Any city or county which structure permit reconstruct,alter,
¢ ¢ ¢a, improve,demolish,or repair any structure,prior n its issuance,also ELEC.CONTR. LIC.NO. +.
ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
q w m he is licensed pursuant to the provisions of the Contractor' License '
HiQ Law(Chapter 9(commencing with Section 700()o(Division3 oCtheArA
4 D Business and Professions Code)Or that he is exempt therefrom and QTY. PLUMBING PERMIT FEES
(C o the basis for the alleged exemption.Any violation of Section 703 L5 1, S ES TYPE CONSTR.
a 3 m by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500L) ALTER-DRAIN&VENT-WATER (EA.) 4.00IS in .
❑ Las owner at the property,Or my,and the
wages as • BACK FLOW PROTECT.DEVICE 2.00 c. RES.UNITS
their sole compensation,will(S the work,and the structure is not
,. intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND, 4.00
a"4,
Code:The Contractor's License Law does napply to an owner of - /v/i- O -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP . '4L00 ,SEE FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS L00
or improvement is a burden
o one year of completion,the owner- GAS-EA,SYSTEM-OVER 4 IEA.) .1.00 BUILDING USE
prover will have the burden.of proving that he did not build or im-
pro 1,as owner of the p h INDUSTRIAL.WASTE INTER. 20.00 . RES ,.IND' ,CON PS Omer
❑ L as Owner of the property,he 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 Contractor's License Law does not apply - � '
to an bwner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 `
contracts for such projects with a contractmis)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ',B.&P.C.for this
reason WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM, ;_ 4.00 - ACC.DATE, ACC.FILE NO.
WORKFRS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self roure,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). ,
Policy No. Company -
' Certified copy is hereby furnished. FIRE SPRINK ENERGYTZO
Z Z ❑ Certified copy is filed will, the city inspection division. - C
F O Applicant MISC.- REFER TO ORD. Y❑ At ! ,_Y ❑ N❑
� y CERTIFICATEOF-EXEMPTION FROMWORKERS' - PERMIT ISSUANCE .6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.• -
CL "firm o This a [idn nerd not be completed if the penult I5 far one TOTAL V❑ . No Y❑ . N❑
U V hundred dollars($100)orlem.) -
I certify that in the performance of the work far which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall nut employ any person in any manner so as to -
O-V be,mnf�t ,f I to the Workers'c�yypensetion L wgyC Calil'or in. -
D:ne TApplicant///�f' f �(LL,�f ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE:TO APPLICANT: If,after making this Certifica eY of Ex- -
F. Z ' emotion,you should become subject to the Workers'Compamution APPLIANCE "• - 4:00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with I FEE
U such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10AWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOGflM.) 5.00 T SEISMIC FEE .
I hereby of firm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perimmarce of the work for which this permit is issued(Sea MICROFILM,
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 '
' LcndeAdde
Lender's,%Address HEATING UNIT(OVER 100,000B.T.U.P.50 ELECTRIC
`
. Icertify.that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER (3 H.P.Of 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and -
hereby authorize representatives ec this city es enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
„ hereby
above-mentioned property for inspection purposes. -
'(We) agree to save; indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which - ,CONST.TAX
may in any way acct against said City in consequence of the PERMIT ISSUANCE 3.00
grand of this n MECH.CONT. LIC.NO.'' MECH.
� ,� �� TGTAL
'Signature of Applicant/Contractor TOTAL
, Date
OFFICE COP Y; -