5875 (4) APPLICANT TO FILL,IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' PERMIT NUMBER
-.'BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING PE
.
ADDfleu�O�� !! e, '� 5875
1 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
NAME
�a� •, '- PLAN CHECK VALIDATION
"AME DTV ELECTRIC,;,PERMI FEE
�fof1E FEDf./Tf}-C •,W ,, •x
CONTRACTORS
NAUTLETS-SWITCHES•RECEP '5.00I100 '
GAS LIL.NO.237265 LIGHTING FIXTURES 5.00/1.00
A DRESS ns / C , s•�. PPLIANCES-RESIDENTIAL 4.00
A O1 r/CY r r/
B PHONEa. /7 PANELS 5.00 DATE OF APPLICATION
AARCHITECT SIGNS 6.� PLAN CHECK FEE P.C.NO.
on ENGINEE •eft A
�25`2'L�I LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - PERMIT VALIOATION
ADDRESS - SPECIALCIRCUIT '5,00 .
ZIP TEMP.METER OR POLE-INS. 15.00
APPuc rs MOTORS _ SEE FEE SCH.
��V➢1 Rl / SERVICE CHANGE 10.00
w o o LICIiNSEDCON'rRACfORS DECLARATION
r i u I hereby affirm ilial I am licensed under provisions of Chaplet 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and B ELECT. PLG. MECH.
H m Z Professions Cod and my Iccnse is in full force and effec. UCT ❑ ❑ ❑
z O as - • Licenn�l 1 Lic.Number I
m w Date Contractor-��y_
a m s - Clt `" ..x. BUILDING P RMIT
aonO OWNIiR-BUICUER DECLARATION MISC.— OORD � '-�1-N bQRMARION.
w se r I hereby affirm that I am exempt from the Contractor s License _ VqL TION $/FT.
HLLO¢' Law for lire followingresson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 6.00
3 w i Code:Any city or county which requires permit to construct,alter, l/ems]
O improve,demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIC.NO. ELEC. //
i w a M requires the applicant for such permit to file a signed statement that TOTAL 1PE�MI O
he is licensed pursuant to the provisions of the Contractor's License -
H' i Luw(Chapler9(commencing with Section 70ODDI'Division3oflhe wfk -
F i ao Business and Professions Code)or that he is exempt therefrom and OTY' -"' - .PLUMBING PERMIT',{ - FE,I
Be 1- the basis for the alleged exemption.Any violation of Section 7031 5al€$vU TYPE CONSTR.
by any applicant fora perma
il sub/eels lhepcivil penalty plicant lot cALTER-DRAIN -WATER (EA.) 1 L Petino
of not more than five hundred dollars(5500).):
❑ 1,as owner of the properly,or my employees with svtgeszs BACK FLOW PROTECT.DEVICE 2,00 ocC.GROUP RES.UNITS
their sole compensation,will do the work,and,the structure 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 does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP4.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
.De
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4OUTLETS 4.00
nts are,aw intended or offered for sale.IL however,the building
Or impjiAement 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 he did not build or im-
prove for purpose Dfsale.). INDUSTRIAL WASTE INTER. 20.00 RES INo N , PB Omar
O 1,as owner of the property,ran exclusively contracting with El ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS SPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and wife LAWN SPRINKLERS-OVER 5IEA) 1,00
contracts for.such projects with'a contractods)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
• ❑ lam exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
--
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a eertilicm a of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Sec.3800,Lab,CA -
Policy No. Company
O ❑ Cerlified copy is hereby furnished. FIRE SPANK ENERGY T 24
_z 2 'f3 Certified copy. is filed with fire city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ NE] V E] NE]F— T PERMIT ISSUANCE 6,00
LU CERTIFICATE COMPENSATION
INS FROMWORKERS'I2KERS' .FLOOD ZONE A.L.U.C.
CL O COMPENSATION INSURANCE ,- PLG,CONTR, LIC.NO. - TOTAL V❑ N❑ V ❑ N❑
Z (This section need not be completed if the permit is for one
hundred dollars(SIOO)or less)
U O 1 certify that in the performva of the'work for which This per DTV.,6 y AAECHANICAL PERMIT - FED
FEE SUMMARY
LL F mit is issued,I shall not employ patio any manner so as m _ y•,,'y-y '
U hlsonr�I eeht0 the Worker' r ansa aws of Calil'orma. ''" BUILDING
a Date_Q1.7�Apr lic ALTER OR ADD TO MECH 4.00
>. W NOTI TO AI'PLICAN ,after making this tificale of Ex-
F ? eruption,you should he- me subject to the WorkLra'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the lab r Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY . AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE S_O
I herebyaffirm that mere is a construction lending agency for EXHAUST HOOD WITH DUCT) 2.00
the30 peC'i rC once of me work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATI NG UN IT ER 100,000 B.T.U.)7.50 / t?-
Lender's Address ELECTRIC , D
' I cattily that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
.j(:fannalion is correct. I agree to comply with all city and COUOty PLUMBING
ordinances and slate laws relating to building construction, and BOILER•COMP I3H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abgve-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 PERMIT ISSUANCE 3.00 ' CONST.TAX
may in y.way accrue again id City in consequen of the
gran' 's per t. MECH.CONT. LIL.NO. MECH.
TOTAL {7
,- n of Applic t/ rector Date
TOTAL;''' CJD
OFFICE COPY