4640 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI- POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BNILGING APPLICATION & PERMIT 4640
ADDRESS I DOD �
I � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME �{ i TV. ELECTRIC PERMIT FEE
/ �J
HONE
0 NoI TORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
IIY/ LIGHTING FIXTURES 5.00/1.00
CONTRACTOR SPPLI ANCES-RESIDENTIAL 4.00
ADDRESS `
AM
OrvE PANEL$ 5.00 DATE OF APPLICATION
ARCHI ECi SIGN$ 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LOC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
00 LICENSED CONTRACTORS DECLARATION
rt v I hereby affirm that I am licensed under Provisions of Chapter 9 ISSUANCE DATE
(Commencing with Section 7000)of Division 3 ot'tire Business i nJ BLDG. ELECT. .PLG. MECH.
Pi " Professions Code,and my license is in full fur f ❑ ❑ ❑
zo License Class�-,y�-Lic.Number
0 z w DaleY`^�LContraclor_
BUILDING PERMIT
a w u OWNER-BUILDER DYCLNRA'I'ION INFORMATION
wLL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LLoro Law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION SIFT.
- Code:Any City m county which reyuiresa Permit tDcon EncLalleq 6.00
rt . 40 improve,demolish,or repair any structure,prior to its issuance also ELEC.CONTE. LIC.NO. ELEC.
-
0,
requires the applicant for such permit to file a signed Matemunl that - TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of tire Contractors License
Hzj Law(Chapter9(Commencing with Suction 7000)of Division 3 of the
a Rosiness and Professions Code)I,,that he is exempt Ill eretrnor,and QTY. PLUMBING PERMIT FEE
r c the basis for the alleged exemption.Any violation of Section 703 L$ STORIES TYPE CONSTR,
a ; m by any applicant for a permit subjects the applicant to a0vil Penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00
of not in than five hundred dollars(S5001.)'.
❑ L a owner of hire property,or my employee with wagesas BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and circ slnaWm is non
intended or offered for sale (Sue, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law duos not apto un owner of
property who builds or impnwes thereon,and wlmply docs such work FIXTURES-PER TRAP 4.00 so.FT FLOOR AREA TOTAL ACREAGE
imself 0r through
his own cmplOycEs,PnrvideA than such Inhpmve-
Lotair of included or offcmd lorwdhowever.
u.If, the holding GAS-EA.SVSTEM-11NC.40UTLET54,00 -
r imProvement Is Sold within one year of cnlnplceon. 0m n
awcr- GAS-EA.SYSTEM-OVER 4(EA,) 1.00 BUILDING USE
uilder will have the burden 0f RE...fog that hedid not build or in'. RES IND CON PB Omer
orove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ Las owner of tic Properly,um exalmively contrucling wilh
licensed contractors to construct the project(Sec, 7044. Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:Thu Contractor's License Law Anes not apply
to an owner of property who raids or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1,00
contracts fur such projects with a c....H rlsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under SEC. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 qCC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of eOOSCnt to xdl'-insan, ZONING ENG,SITE NO.
0r pay cJe�rt[if�iqcfa�te of WWW.l.p�$o(Q,0k�/Ieirsq bCIOmpiaAl- sur Ic�i•.I or'a Reel
O P [3` Te11iNe� s-yls fl`•ICbyylurnished. FIRE SPHINK ENERGY T 24
Z_ Z ❑ Certified p f}l}d w' ty i s ion 1 - MISC.: REFER TO ORD. Y E] N Y ❑ NE]
I- � Applicant
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
� > CERTIF ONIP17 ISATIO fINSU RANI WORKERS'
ll.l COMPIiN$ATION INSURANCE PLO.CONTE. LIG NO. PLG. V[] NE) YE] RE]
d o (This section need not be completed if the permit is for one TOTAL
0 Z hundred dollars(S 100)or 1esS.1
U O 1 certify that in the performance of the work for which this per- OTV, MECHANICAL PERMIT FEE FEE SUMMARY
I H mit is issued,I shall not employ any person in any manner so as 10
O w become subject to the Workers'Compensation laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4,00
)_ y NOTICE TO APPLICANT: If,after nicking this Certificate 0(lix-
F" Z emption,you should become subject to lire 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 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2,00
the performance of Ore work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.M50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that lire above VENTILATION FAN (SINGLE) 3.00
information iz state. I agree tit)
with all ei,y and county BOILER-OOMP(3 or 100000 BTU) 400 PLUMBING 0,
ordinances and slate laws relating , building court mot ion, and H.P. , . . . .
Hereby arhoriec representatives of this city In enter upon the BOILER-COMP love,100A00BTU)SEE FEESCH. MECHANICAL
above mentioned property for ins'pectino purposes.
(We) agree to save, indemnify and keep hunnlass the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs mol expenses which CONST.TAX
may in any way accrue against said City in sequence of(hc PERMIT ISSUANCE 3.00
grantln&uf this permit EC H.CONT. LIC.N0. MECH.
Q�11lQm a- 1a5 DTAL TOTAL I "
sig rc of Applicant tractor DIIte
OFFICE COPY