4553 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION P EMIT NUMBER
APPLICATION & PERMIT
A�O Es
BUILDINGU Tr`� 4553_
1 �\U
BUILDING —ELECTRICAL—PLUMBING—MECHANI
OWNER'S ^ C� PLAN CHECK VALIDATION
�"""� D ,{^RT� QTY. ELECTRIC PERMIT FEE
L.` �U�"'1 PNONE
CONTRACTOR S
N ME u OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
rorvRRAcrc ' 1'1 S.`. APPLIANCES-RESIDENTIAL 4.00
aDoREss a
1 HON PANELS 5.00 DATE OF APPLICATION
ORRCNITECTI
SIGNS 6.00 PLAN CHECR7 P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS END SPECIAL SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
02 LICENSED CONTRACTORS DECLARATION
a v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA CE DATE
H rt y (commencing with Section 7000)of Division 3 of file Business and BLDG. ELECT, PLG. MECH.
H g z Professions C al icense is in full f f /-� ❑ ❑ ❑ ❑
Z, o m — Licen lu Lie.Num a 1t,
D t Date — Coil mcto
a m BUILDING PERMIT
¢ ¢o OWNIi R-BUILDER DELL RATION INFORMATION
La ; N I hereby f
afirm Dat I ant exempt from the Contractor's License MISC.— REFER TO ORD
u. O¢ Law for the following•reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
H _ PERMIT ISSUANCE 6.00
Ewe Code:Anyciryorcounty which requires a permit to construct,alter,
¢ Be ¢D improve,demolish,or repair any structure,prior la its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w a O K requires the applicant for such permit to file a signed Vateamat that TOTAL PERM I TO
n w m w he is licensed pursuant to Elie provisions of the Contractor's License
Hz> Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
¢ Business and Professions Cod.)or that he Is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4,00
of not mare than five hundred dollars($500),):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 2.00 OCC.GROUP REB.UNITS
LT sole compensation,will do the work,and the structure is not
intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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 TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improver
mems are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
or improvement is sold within one year of completion, Ile owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). RES IND CON PB Coals,
❑ I,as owner of the property,am exclusively contr:mlmg with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044, Businoss LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 conlracfor(s)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,N.&RC.far this WATER HEATER W/VENT 4.00
reason
Dae Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORK ERS'COMPENSA'TION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate nfconsent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy th r• uh.
Policy any ,J�s`
O ❑ Off 'opy is hereby I in hed. FIRE SPRINK ENERGY T-24
z Cer if• y 'tl '1 MISC.- REFER TO ORD.
Q AI IiC.m _ _ Y❑ N❑ Y ❑ No
cc CE I ICA'ni OP liXf:.'ll ON'FRO ORKERS• PERMIT ISSUANCE 6.00 FLOOD ZONE a.L.u.c.
W COMPENSATION INSURAN E PLG.CONTR. sec.No. PLG.
CL Q ('Phis section need not be completed if file permit is for one TOTAL Y❑ IN Y ❑ IN
D Z hundred dollars IS 100)or lees,)
U O 1 certify that in the performance of the work for which this per, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ anon y persin any manner ,,as to
O W become subject to the Workers'Compensation Laws of Calitornia.
y DateApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: IL after making this Cerfil'icatc of Ex-
H.. 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 1 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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOWC.F.M.) 5.00 SEISMIC FEE
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. -M ICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 s
Lender's Name HEATING UN IT 100,0008.T.U.)7.50
Lender s Admess ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct, I agree to comply will,all city and study PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00 AA
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL vel
above-mentioned property for inspection purposes.
(We) agree to Save. Indemnify ad keep harmless the Cify of MISC. R E FJE R TO,044 D.
Cupertino against liabilities,judgments, costs and expenses which PER IS CE 0 CONST.TAX
may in any way aceto, against said City in cnnuqu.nce of the Q
g 'IS of this pen MECH.CONT. LIQ N M CH.
v�` `ke - f%540 TOTA TOTAL
g lure of Applican/Compacm Date I
OFFICE COPY