5677 (2) APPLICANT TO FILL IN.INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATION
PER MIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESSOREss " BUILDING—ELECTRICAL-PLUMBING—MECHANICAL 5677
•
OWNER'$ - - -- -- PLAN CHECK VALIDATION
X NAME CITY. ELECTRIC PERMIT' FEE
504!1) JhN1L^^S 44
PHONE 6-2-134
NAME ACTOR
's UTLETS-SWITCHES-RECEP 5.00/1.00 -
L10•COFGL LIC.NO."z 58 (0 LIGHTING FIXTURES 5.00/1.00
ADDRESSTOR's APPLIANCES 4.00
$131 Ma12NJYRK hIrv. CuIrL 3oI
S/1Vx1 8517-5 PHONE PANELS 5.00 DATE OF APPLICATION
AARRCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG. SPECIAL CIRCUIT ,5,00 PERMIT,VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
AMOTORS - SEE FEE SCH. (�1)//►�//[I'�
ADDDRESSDRESS -
SERVICE CHANGE 10.00
I
wo o LICENSED CONTRACTORS DECLARATION
C ou, I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z (commencing with Section 7000)of Divlslon 3 of the Business and
rn< m BLDG. ELECT: PLG.,. - MECH,
0 Professions Codyy�na{n license is in full to�c�e f(e et.
Z. z H o License Cl ss u Lie.Number_',I^`1�!5',�` - �' El
�;`
m r w
Dar Contractor +F� '
M Y s < Pg41�4,QING PERMIT
¢ 0 6,O OWNER-BUILDER DECLARATION RR/1IIKKDDRMATION
w ; LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
1) 0 ¢ Law for the following reason.(Sec,7031:5,Businessand Professions VALUATION $/FT.
— PERMIT ISSUANCE 6.00'
Code:Any mulish,or countypair any structur e p tion to construct,, ter,UISO (77/7!rl y a fl
Q Q Q D
improve,demolish,or repair any Structure,prior to its issuance,x150 ELEC.CONTR., LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is(Chapter
pursuanten and provisions of the Contractor's License �.r,�" _a
Etle
E
Laww(Chand Profession,
Cngwhh Section is 00)exempt
and
0, 4 o Business and Professions Code)or that he is tion of therefrom and QTY. PLUMBING PERMIT FEE -
2F $ thebasisappli the alleged orermit subjects
Any applicant
to a Cion malty STORIES TYPE CONSTR.
n3 — by any applicant fora permit subjects $5001.licant loacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mate than five hundred dollars(my em): -
❑ 1,as owner at the property,or or employees with wages as BACKFLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
!hair 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
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work ''FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
r himself or through his own employees,provided that such improve-
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 4,00
Or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
f builder will have the burden of proving that he did not build or im- _
for RES IND CON PB Othar
prove 1,as owner
of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ '❑ ❑ ❑'
❑ d as owner of the property,he exclusively contracting with
licensed croons od to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL No. -
and Professions Code: ty Contractor's License Law does,not
and who
,
to tr owner of property who builds tr improves(hereon,uand who LAWN SPRINKLERS-OVER 5(EA.), 1.00
the Contractor's
for such projects with o con[mctods)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 WATER HEATER W/VENT 4.00 ,.
reasom
Owner Duro WATER SYSTEM 4.00 ACC..DATE ACC.FILE NO.
V{[ 597 t O'I-8y - -
�N'ORKERS'COMPENSAT16N DECLARATION WATER TREATING EQUIP, 4.00
_ ercby affirm dis I have a certificate of consent to self-insure, - ZONING
ora rtdicatt of Workers'Compensation Insurance,or a certified ENG.SITE NO.
di
[h cot(Sec.3800,La B.C.I.y��� _
Policyy No. Company TICP�LLL
0- KCerti tied copy is hereby fumished. FIRE SPRINK ENERGY T-24
Z_ Z 0 Certified Iled glib the city inspection division. MISC- REFER TO ORD.
O 'APplican o - - Y ❑ N❑ Y❑ ,NEI
~ rn PERMIT ISSUANCE 6.00
� — CE (FICA Fi OPE I I N FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPP,NS N I SURANCE PLG.CONTR. LIC.NO, PLG.
Z (This section need not be completed if the permit is for one TOTAL Y N Y ❑ N
hundred dollars($100)or less.)
'0 O' 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
'LL H mit is issued,I shall not employ any person in any manner so as to p C�
OW become subject to the Workers'Compensation Laws of California. BUILDING .Jp ��'
y Dale Applicant .' - ALTER OR ADD TO MECH. 4.00
. } w NOTICE:TO APPLICANT: If,after making this Certificate of Ex-
FZ emptiou,you should become subject to the Workers'Compensation APPLIANCE 4.00 .'PLAN CHECK
,provisions of,the Labor Code, you must forthwith comply with FEE.
V such provisions or this permit shall be deemed revoked. . AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00 '
CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER.10=C.F.M.) 5.00 SEISMIC FEE " Sa
I hereby affirm that them is a construction lending agency for .y EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit Is issued(Sec.. - MICROFILM
3097,Civ.C.). ,v .'i. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address - 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 county • PLUMBING
-
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.Ror100,000B.T.U.) 4.00
hereby authorize representatives of this city In enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH, MECHANICAL,
above-mentioned properly for inspection purposes: -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iia ilities,judgments, costs and expenses which CONST.TAX
may in a c rest said City in consequence of the -PERMIT ISSUANCE' 3.00
granlin 4 5 e i[ MECH.CONT. LIC.NO. MECH.
l� TOTAL TOTAL 4TH
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• r 0FFICE COPY