5706 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
BUILDING 5706
ADDRESS (
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER 5 C(L �" PLAN CHECK VALIDATION
IZG� OTY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME UTLETS-SWITCHES-11ECEP 5,00/1.00
NAME
sea .L ,No, L LIGHTING FIXTURES 5.00/1.00
CONTRA Toss iv APPLIANCES-RESIDENTIAL 4.00
ADDRESS
r PHONE qLoq, I, PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
i OR
ENGINEER
SIGNS TRANS. 3.00
ARC HRENG, SPECIALCIRCUIT Sj,QQ PERMIT VALIDATION
ADDRESSZIP TEMP.METER OR POLE INS. 15.00
APPLICANT's MOTORS SEE FEE SCH.
ADDRESS
-
(• _ _ TiekUMTCE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION U
2 v U 1 hereby affirm that I am licensed under provisions of Chapter 9. ISSUANCE DATE
aa,< N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Cop sµ1 y license is in full fur'• Tec. ❑ ❑ ❑ . ❑v
z o w— Liccnsc ClassS}"h��_Lic.Numbe
O u F w Dalc Contractor
¢ m s - a� r BUILDINGP,ERMIT
¢ ¢ W Q OWNER-BUILDER DECLARATION
0 A D — REFER TO ORD INFORMATION:
w0 LL n 1 hereby affirm DoMISC.t 1 am exempt from the Contractor's License VALUATION $/FT. ^
u.oa Law for the l'ullowins reason.ISca 70315,Businessand Professions PERMIT ISBLANCE 6.00
F W Code:Any city or cou my which reyuiresa permit tocoma uel,alleq
e ¢a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. t
KOY requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt Iherclrnm and OTV. PLUMBING PERMIT FEE .Q_—
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
dam_ by any applicant for a permit subjects the applicant tea civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500L):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITtJ
their sole compensation,will do the work,and the structure is not
in ended or oll'ered for sale(Sac. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND- 4.00
Code'fhe Contmeror'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
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
or Improvement is mild within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not buil)or im-
proveforpurposeofsale.). - INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB ohhas
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct 11¢ project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
Md Professions Code:"rhe Contractor's License Law does 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 to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl Iamuxumptunder Sec. ,B.SP.C.fmr this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKS RS'COMPENSA'NON DECLARATION WATER TREATING EQUIP. 4-00
I hereby atlirn that I have a certificate of consent to sell insure, ZONING ENG.SITE NO.
or a certificate id Workers'Compensation Insurance,or a certified
copy there (SS ,�i00 Lub.C.l. 1� _�
Policy No. i}�JGC p _ �"� .:�sxr �!-
0 ❑ Certd ie c)py iisslrr� by arnishT�_ FIN E SPRINK ENERGY T24
Z_ 241LU�it i� - 1 the, i spccii (I division. V MISC.- REFER TO ORD. E] N C] V [3N❑
Applicant
F— aI E : S'
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
— CER1'IFICA'I"li OF li%I'MION FROM WOR
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C ❑ ('Phis section need not he conmleted if IIIc Permit is lilt one TOTAL v❑ N❑ V❑ N❑
Z hundred dello,(S 100)or Iess.)
L) O 1 certify that in the performance ol'the work for which'his per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY,,,,
LL H mit, so
is issued,I sliall not employ any person in any manner/)as to
Ow become subject to the Worker Compreamn lawsof Calimmia. BUILDING
Dela APPlumnt I ALTER OR ADD TO MECH. 4.00
} 10 NOTICE 'f0 APPLICANT: It,alter making this Certificate of Ex-
F Z emplion,you should bee ome subject to the Workers'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 deenmd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCf1ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE t
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(Sec. HEATING UNIT(TO 100,000 B.T.U.) '4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UNIT(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
• hhh)nnation is correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING '
nnlinmres and stale haws relating to building construction. and
hereby authorize representatives ol' this city to enter upon the BOILER-COMP(Ov4r IOg000BTUl SEE FEESCH. MECHANICAL
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 PERMIT ISSUANCE , 3.001 CONST.TAX
may in any way accrue against said City in consequence of the
gmNingof lhispernit. • MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL JI
4m lure oJ Applicant/Contrac(ilr NDate s
OFFICE COPY