4810 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
PERMIT,NUMBER
Y,L 0
BUILDING
�
aooREs '
J �y . v/ �/e BUILDING - ELECTRICAL-PLUMBING-MECHANICAL )`jJ
OWNER's PLAN CHECK VALIDATION
NAME
,,(( / _y - DTV. ELECTRIC PERMIT FEE
J YE 1641 C-/` PHONE 2-) J -c-9-
CONTRACTOR"S
NAME / n ' / 'OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC,NO. )�.Ff-'f LIGHTING FIXTURES 5.00/1.00
,ONTRACTORs PPLIANCES-RESIDENTIAL 4.00 '
ADDRESS
yp PHONE r'L�7Y PANELS 5.00 DATE OF APPLICATION
ARRCHITECT ,SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEEfl
- LIC.No. SIGNS TRANS.' ,3.00
ADDRESS END - SPECIAL CIRCUIT ' 5.00 PERMIT VALIDATION
zIP rrEMP.METER OR POLE INS. 15.00
APPLICANT MOTORS SEE FEE SCH. 341-1-3
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION A
¢ U U I hereby affirm that I our licensed under provisions of Chapter 9 ISSUANCE DATE
H< y (commencing with Section 7000)Of Ulvlslon 3 of the Business ao BLDG. ELECT. PLG. MECH.
F 7 i Professions Code,aed mm,yy 1/eense is in full force:n ❑ ❑ ❑
Z o„- License Class i -7 Lic..Number
2 u w Uate Contractor
y s _ BUILDING PERMIT
w OWNER-BUILDER DPCIARArION 1 INFORMATION
oA MISC.- FER OORD
g u w 1 hereby attain that 1 am exempt from the Contractor's License ��..��((ALUATION $/FT.
H LL O a Law for the following reason.(Sec 7031 5,Business and Professions PERMIT ISSUANCE 6.00 IY
Code:Any city or county which requires a permit to construct,alter, ''11
a ¢ improve,demolish,or repair any structure,prior to its issuance,clan ELEC.CONTR. _IC. LEC, 04•�
o ¢ requires the applicant such permit m file a signed statement Dint TOTAL I �^��
i w m u I l't. `J• PERMIT TO
he is licensed pursuant to life provisions of the Contractor's License
ryQLaw(Chapter 9(commencing with Section 7000)of Division 3of the
Business and Professions Code)or that he is exempt therefrom unit OTY. PLUMBING PERMIT FEE e'kvv
M =$ the basis for the alleged exemption.Any violation of Section 7031.5 .S7MJFS TYPE CONSTR.
Dm `B
t by any applicant for a permit subjects applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.0
PGIUDU
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OG GROUP RES.u ITS
their sole.compensat ion,will do life work;coral the sl raclure is not -
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Ytt�R- •r �/`7�
Code:The Contractor'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 TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale,If,however,the building - GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
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 not build or im-
for RES IND CON PB Ont,
prove 1,as owner
of sole.). - INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner rs the instruct,he project
iv Se contracting with
licensed cOions od to construct the project Bec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and n owner of Code:The who
builds o improvense Law citieshreon not apply .
co an owner of property who builds tr improvesehereon,and who LAWN SPRINKLERS-OVER 5IEA.1 1.00
the Coots for such projects with o conlracmrts/licensed pursuant to
the Contractor's License Luw, I SEWER-SANITARY-STORM EA. 200ft/5.00 TRACT NO, PARCEL NO.
❑ I am exempt under See. ,BAP.C.for this WATER H ATEA W/VENT - 4.00
reason
Owner- WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKIIRS'COMPENSATION DECLARA'r1ON WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sac.3800,Lab.C.). �, t
Policy No. Company f.j/�
O ❑ ,�CCertified Impy is hereby R ruffs e - FIRE SPRINK ENERGY T-24
_Z Z N'Cerlifies� cop is BI with'tge city inspection division. REFER TO ORD.
.
O Applicant -�Lv� f�Cw• v❑ N E] v E] N❑
r4 PERMIT ISSUANCE 6.00
LU CIiRTIFIC9WIPENiATIOl'INS FROM WORKERS' FLOODZONE A.L.0 c.
W > COAIPENSATION INSURANCE PLC,coNTR. LIC.N0. PLG.
CL Z( TE]his section need not be completed if the permit is for one TOTAL Y N❑ Y❑ NC]N
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of tire work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner us as to
U become sgqb'e t t e Workers'Cgy�pen`s-al}'o I: sof lifdrnia.
O w Dmc1/�A plicant [Z '-x- BUILDING .R�
a fC p ALTER OR ADD TO MECH. 4.00
} to NOTIC: T AI LICANT: II',after makinlL,(Js is Certificate of Ex
F 2 emption,you should become subject to the orkeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of Dm Labor Codc, you must forAlwiD1 Comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE SU
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perforreance'of the 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 HEATING UNIT(OVER 100,000 B.T,U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is Correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to builJing construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 4.00
hereby au tion" representatives of this city Io enter upon the BOI LER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection Purpose'
(We) agree to save, indemnify and keep harmless the City of IS
- 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 Consequence of the
granting of this permit MECH.CONT. LIC.NO. MECH.
S �vC�zJ�-� r�3�F�
TOTAL TOTAL q 43
Signature of Applicant/Comrade, Di
OFFICE COPY