4726 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4726
ADDRESS BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
a0q Pr � C� .
OWNER'S � � � PLAN CHECK VALIDATION
NAME _f'_r' fEJJ �J QTY. ELECTRIC PERMIT FEE
n�S l-Ct PRONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1,00
NAMEIt>
s Is(`. ifp I L''(. LIC.No. LIGHTING FIXTURES 5.00/1.00
ACONTRACTOR sJ���/Kc APPLIANCES-RESIDENTIAL 4.00
ADDRESS /`/7
y� PHONE O- SCO PANELS 5.40 DATE OF APPLICATION
ARCHITECT- SIGNS 6.00 PLAN CHECK FEE P.G NO.
OR
ENGINEER LIC 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 /o
SERVICE CHANGE 10.00 /, '
w o o LICENSED CONTRACTORS DECLARATION RATION %I G
¢ v U I hereby affirm that I am Iice,ad under prrvisime,of Chapter 9 O ISSUANCE DATE
IP
Q (commencing with$eclinn ]000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F HZ- Professions Code,and y license is in full for a def cat ❑ ❑ ❑
Z o ,4 - Lice a Cla s J Tic.Number
o z H w Dafe Contractor
a y 4 BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARA'I'[ON INFORMATION
REFER TO ORD
E
3 n H 1 hereby affirm that I am exempt from the Contrunor's License MISC.- Ir.�Lr y.EI�,�ION $/FT.
FLL0 s: Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 }jam'(/�Ja�U•
Code:Any city or county which requires a permit to construct,alter,
¢ ¢< 0 improve,demolish.or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC.
- 0 M requires the applicant for such permit to file a signed statement that TOTAL TO
n w hu is licensed pursuant to the provisions of Ilia Contractors License EQ 13 1
Fzi
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the -�
E i a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 I & TYPE ONSTR.
i ; $ by any applicant for a Permit subjects the applicant too Civil penally Al kt
of not more than five hundred dollars($500).) ALTER-DRAIN -WATER (EA.) 4.00 cD. �664
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 O£O.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not a
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 erCNG S%4P(Fx{
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dol.,such work FIXTURES-PER TRAP 4.00 90.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such imProve- -EASYSTEM-11NC.4OUTLETS 4.00
ints are not intended or offered for sale.If,however,the building GAS
or improvement 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 nnl huilJ or int- RES IND CON PB One,
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00El ❑
❑ I,as owner of file property,um exclusively contracting with
licensed contractors m Construct the project(Sce. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'life Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such Projects with a contractods)licensed purvuunl to
Ilia Contactor',Lice use Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL No.
❑ lura exempt under Sec. .B.&I'.C.fur this WATER HEATER W/VENT 4.00
Data Owner WATER SYSTEM 4.00 ACC.PATE ACC FILE NO,
WORKERS'CONIPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
1-hereby affirm that I have a certificate of consent I.setfinsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereoflSuc,3800,Lab.C.).,
Policy Nn. Company
Q ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ Ni
Applicant
CCPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
- CIiRT'IPICAT Ii 0171 AEION INS FROM WORKERS'
LU 1 COMI'ENSA1'ION INSURANCE PLG.CONTE. LIC.NO. PLG,
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z himdrud dollars IS 1001 or IessJ
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F. mit is issued,1 shall not employ any person in any Renner so as to _
O W heart, sl�h,e�at the Workers' - npcnsaD aw If Calif' rnia. a
Uatc plllicani ALTER OR ADD TO MECH. 4.00 BUILDING l�LfC S
} w NOTICIi TO T (CANT: It.after making this Certificate of Ex-
F ? eniptfon,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you muse forthwith Comply with FEE
U such provisions or this permit shu11 be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
ore performance of the work for which this permit is issued(Sec. MICROFILM
3097 Civc) 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 unit stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
10 ordinances and state laws relating to building conzfill Ill , and
hereby aulhoriee representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. 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 3.00 CONST.TAX
may in any way accrue against said City in couguence of the
granlin of this permit MECH.CONT, LI C.NO. MECH.
1 Ig 3 DTAL TOTAL �f�v
Signature or ApplicanllContactor Dare
OFFICE DOPY