4354 (2) APPLICANT TO FILL IN INFORMATION WITHIN'•RED LINES - USE BALL POINT PEN ONLY . ,
BUILDING PROJECT IDENTIFICATION . PERMIT NUMBER
\, aunalNG 'APPLICATION'& PERMIT {� r1 C, A
T ADDRESS Y J �J'1
BUILDING,-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - -- - -- - - - ---- -- _--'- - ---��� PLAN CHECK VALIDATION,
1" NAE ` OTY. ELECTRIC PERMIT FEE
' PHONE 252, a
Cob $
�� OUTLETS-SWITCHES-RECEP 5.00/1.00
ryrs q, S uc.No. Y7SS6Sz LIGHTING FIXTURES 5.00/1.00
r,ONTRAC7OR*S A PPLIANCES-RESIDENTIAL .4.00
A
pop SS
�j ^� app
)'3%-t Jq J
PHONE /0'08? PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER '
LIC.No. SIGNS TRANS. 3.00
AR.08 ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
zu, EMP.METER OR POLE INS. 15.00
APPLICANTSMOTORS - SEE FEE SCH.
ADDRDDRESSSS
• SERVICE CHANGE - 10.00 /V�
Doo LICENSED CONTRACTORS DECLARATION VVV
X v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y< (commencing with Section 7000)of Division 3 of the Business and n BLDG. ELECT. PLG. MECH.
F Professions C a m license is in(all far c V ❑ ❑ ❑ ❑
Z o License Class - Lie.Num
2 Z Date _G_r}Conrract
y s B LDINO PERMIT
tc w ¢ OWNER-BUILDER DECLARATION ATION
D a MISC.- REFER TO ORD
K
g LL u I hereby affirm that I am exempt Gain the Contractor's License VALUATION $/FT.
FUDv, Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 6.00 j� Q"�
,A0 Code:Anycityorcounty whichrequiresa permit reconstruct,alter, ELEC. LIC.NO. r'L.T�/L (J
e; p improve,demolish,of repair any structure,prior m its issuance,also ELEQ �
D LL requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
F$a he is licensed pursuant to cite provisions of the Contractor's License R7{Ir�ftJo e�
i Law(Chapusr 9(commencing with Seetlan 7000)of Division 3 of the /F(tf7 '1ms�s
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE 'M
H 0 the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
by any applicant for apermit subjects the applicant Ica penalty ALTER-DRAIN&VENT-WATER (EA.),4.00 CC2'7P IN Lsli6r
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wag"as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the I Declare is not
intended or offered for sale (See. 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 theruon,and who(toes such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees;provided that such Improve-
-menu are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4'OUTLETS 4.00 -
or improvement is sold within one year of the did completion,the owner- GAS-EA.SYSTEM--OVER 4(EA.) 1.00 BUILDING USE
builder will have the ale.) of proving that he Aid not build or int
RES N P M1n
prove for purpose of sale.), INDUSTRIAL'WASTE INTER. 20.00 IND CD a of r
❑ d as owner of the properly,he exclusively .7044,tins with ❑ ❑ ❑ ❑ ❑
licensed contractors: construct the project(See.7044,Business LAWN SPRINKLERS-1 INC5V.B. 5.00 ASSESSORSPARCEL NO.
and Professions Code:The who
buildsContractor's License Law fines not aptly
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with mcontractarfsl IicenuA pursuant to -
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT No. PARCEL No.
❑ 1 am exempt under Sec. ,B.&P.C.far this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM X4.00 ACC.DATE. ACC.FILE NO.
WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
❑ Certified copy is filed with the city inspection division. MISC.- REFER TO OR Z U Applicant _ V❑ N❑ Y ❑ N❑
CC N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V N
0. 0 (This section need not be completed if the permit is for one TOTAL v❑ ❑ ❑ N❑
D Z hundred dollars IS 100)or less.) '
U O I certify that in the performance of the w for this Per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not emp any P m n nr so as to
U beco su act ie Worke ensali n
r
O a pate - pplica ALTER OR ADD TO MECH. 4.00 BUILDING
NO CF:-TO AP LICANT: ' ter ma kin t r,treat.of Ex-
F 2. emption,you Should become jest to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U. such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=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 there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
inforinformation is rotted. I agree li comply with all city and county PLUMBING
m do and sate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorieu representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abuve-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 accrue uga' said City in consequence of the PERMIT ISSUANCE3.00
ting of this pea' MECH.CONT. LIC.NO. MECH. /'
• \ 9'(,L TOTAL TOTAL 7-jar 1
liet/0 Date
\J�/ Sigi tae r
OFFIGE GOPY