7069 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY.
BUILDING PROJECT IDENTIFICATION -,r PERMIT NUMBER
9ILDING "
UAPPLICATION &'PERMIT
•/ aD �1'O1L�-� a rt '' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL _ .r 706-9
Dwrvee's - PLAN CHECK VALIDATION
�- NAMI' • , /I = /'� ��� TY. ELECTRIC PERMIT FEE
CONTRACT RS
-SWITCHESRECEP. 5.00/ 00
LIGHTING
=G-FIXTURES, 5.00/11 00 ti
'
CONTRACTORS - - " 3
E �J `1 /A• PPLIANCES�RESIDENTIAL' "4.00 I�f�' 2 riJ IJO
f "/�� Vll�-• rRDN PANELS 5.00 .yv 1"DATE OF APPLICATION '
ARCHITECT. - SIGNS - 6.00 „PLA/N�C{H�E rC�1{('F Epr1 rfRC.NO.
(ENGINEER lYUpO� (HIV
LIC.No, SIGNS TRANS. ," 3.00
ADDRESS ENG' r "SPECIAL CIRCUIT t " _ 5.00 :, PERMIT VALIDATION
nP 11TEMP.METER OR POLE.INS .15.00
APPucnCf.�,�,N/hj-sMOTORS 'SEE FEE SCH.
2- I
ENt (lW l;,(/l/>!W� SERVICE CHANGE -.10.00
woo LICENSED CONTRACTORS DkLARA'1'ION
¢ Z wI hereby affirm thiol am licensed under previsions of Chapter 9 ' 111 ISSUANCE DATE -
w ¢ H . Qo u r .cing,wllh Section 7000)of non 3 of th•Business and - - BLDG. ELECT. PLG. MECJ4.
r z PmlLssmns Co 'r icer full for c L
' a O y L euro.(T•l�s's _ unher o . - _ ❑, ❑ ❑
O m F Om Date tor- -
¢ M J 111 16 '^ _ .BUILDING PER
re ¢¢ - OWNHR ISUILDIik UECLAkATION'
o a u - ' INFORMATION
K
3 u r I hereby affirm'Ihat 1 am exempt front Ore Conoactor's License MISC.- REFER TO ORD
u o j Law her the followin reason.(Sec.7031.5,Businessand Professions - VALUATION S/FT.
_ g .PERMIT ISSUANCE 6.00
Code:'Anycily orcounly whicltrequiresapermillocoTln¢Lalteq -
¢¢2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC
c LL requires the applicant for such permit to file n signed'stateme6t that .t : TOTAL "
u m m he is licensed pursuantPERMIT TO
to the provisions of the Contr.¢tor's License _
to [.:He(Chapter 9(commencing with Section 7000)of Division 3 of the _
4 Business and Professions Code)or that he is cstiopt therefrom and OTY. PLUMBING PERMIT FEE
re 10. the basis for the alleged exemption.Any violation of5ectiun 7031.5 STORIES TYPECONSTR.
byany applicant for a permitsubjects the applicant loll civil penalty ALTER-DRAIN -WATER IEA.14.00
- of not mom that live hundred dollars 185001.):
❑ I,as owner of the properly,.,my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 .Oce.GROUP fids.UNITS
theirsole compensation,will do the work,and the structure is not
intended or offered for sale (Sec.,7044, Business and IYofessions DRAINS-FLOOR,ROOF,AREA;COND. 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 SQ FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
Tentsarenotintendedorofferedforsale.If,however,lite budding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 _
or improvement is;sold within one year of completion,theowner- GAS'-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ire- - - IND CON PB Umer
'- prove We;ofor wnerose
of the,1. INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
c❑licensed as owner of the property,am rojectiv Sec.7 lr4,bu with -
dPocontractors Code: I construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B.- 5.00 ASSESSORS PARCEL NO.-
1.
O:
1. Professions proprty Co loolds s License taw docsnotapply
co an Owner Duchp property who builds tr improves tns d puand who LAWN SPRINKLERS-OVER 5(EA.) 7.00 -
contracts ct is Liclnje L with a conlTelnrts)licensed pununnt m
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL No.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT - 4.00
O on
Owner Dale WATER SYSTEM 4.00 ACC.DATEr ACC.FILE NO.
WORKERS'COMPENSAI']ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm (hal l have a certificate of consent to self-insure, ZONING ENG.SITE NO. '
or a certificate of Workers'Cmnpe tion Insure y or a cer11"ed - "
Cup fj yC.). IL1V1 - ..
1'oli� ICZ y -
0 �"1�C_tnifm hereby f -
z z '�,J[t.erlified sis'�file I c city i !pec' division. FIRE SPRINK ENERGY T-24
O A N MISC.- REFER TO ORD. , v 0 N v 0 No
CC CERTIIICATIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL-U.C.
UJ > 'COMPENSATION INSURANCE . PLG.CONTR. LIC.NO. PLG. ,
-� z 1'Ihis section need nut be completed if the Noun is for one TDTAL '� Y E] NE] Y❑ N❑
hundred dollars(S 100)or less.) r -
U O." 1 certify that in the performance ol'the work for which this per- STV MECHANICAL PERMIT - FEE !tFEE SUMMARY N'6 I'2
LL F mit is issued,i shall not employ any pcnon in any manner so as to ,.
U Income subject to the Workers ns
Compeation'Lawn of California. '
�'.C. Date Applicant - - - ALTER OR ADD TO MECH. 4,00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of rT_
f- ? emplion,you should become subject to the Workers'Compensation APPLIANCE4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U - such provisions or this permit shall be deemed'mtokCd. AIR HANDLING UNIT(TO tOfDOGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p(30C.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 I'or 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
Lendcds Address ELECTRIC
I certify 113,1 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 building construction, and BOILER-CONP 13H.P.Or100,000B.T.U.) 4.00
hereby awhorize representatives of this city to'enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCR. MECHANICAL,
V' above-mentioned property for inspection purposes. r
(We) agree to Save, indemnify and keep harmless.the City of MISC.- REFER TO ORD. - -
' Cupertino against liabilities,judgments, costsand expenses which - - CONST.TAX
may,in an ay accrue insI said City in nwquence of the PERMIT ISSUANCE 3.0 0 () .
grdn i9 pent • MECH.CONT. -LIC.NO. MECH.
C � TOTAL �" TOTAL
1 Stalum of Apphu nl 'i!`lTfta�to Ime
bFFICE COPY • , '