17058 (6) APPLICANT TO FILL IN INFORMAT.,ION WITHIN REDLINES - USE,BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - .PERMIT NUMBER
BD,Lp,N APPLICATION & PERMIT, I�0
npnfc 1 Vi� ,.. I
NLi BUILDING ,-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
'PLAN CHECK VALIDATION
n� NAME OTY. ELECTRIC PERMIT FEE ' n +•
PHONE
CONTRACTORS .
NAME OUTLETS-SWITCHES-RECEP.. 10.00/1.00
uc.No. 'LIGHTING FIXTURES '- 10.00/1.00 " -CONTRACTOR 5 $zJ y/-^_ APPLIANCES. -RESIDENTIAL s 4.00 :
PN/ONE Z',0PANELS 10.00 OA TEOFAPPLICATION
"
PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.NO.
NGINEE
NO ISIGNS TRANS. 3.00 -
ARCH. oADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
D45Am ,It TEMP.METER OR POLE INS. 20.00 (
APPLICANTS
ADOREs MOTORS SEE FEE SCR.
- • ,
SERVICE CHANGE - 20.00,
tea LICENSED CONTRACTORSDECLARATION sJD - 1��0^-v«�
a w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commenc,np with Section 7000)of Division 3 of Ilse Business and
a u a BLDG. ELECT. PLC. MECH.
i Professions Co��yf�yy h ny license is in full fore riff c. - t y�}+k ❑ ❑ ❑
' Co. - Licens Iass$a Lic.Number
2 m �_Conlmdm' • '
a Y - � - BUILDING PERMIT
rca OWNER-BUILDERDECLARATION '
o a v - -- INFORMATION
w ; a. y 1 hereby affirm that I am exempt from the Contrametra and
License MISC.-' REFER TO ORD Apyp y�
.F u_oa hew l'lir the following reason. 7031.5,Business Professions PERMIT ISSUANCE 10.00 : 2r/TTI g/FT.
Code:Any city or county which requires a pennino construct,eller,
2 a ¢o improve,demolish,or repair any structure,prior to its issaancC,also ELEC.CONTR. LIC.NO. ELEC. ,.
0 ¢ requires the applicant I'or such permit to IIle'o signed sla emeal that _ .TOTAL• '
u a,m" he is licensed pursuant to the provisions of the Contractor's License - "' D ERM O
� za
Law[Chapter9(rommincingwith Section 7000)of Division 3 of the - G
s z o Nosiness and Professions Code)or that he is exempt therefrom and DTV. : PLUMBING PERMIT 'FEE
or I $ the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects(lie applicant to a Civil Felinity ALTER-DRAIN -WATER IEA., 5.00 '
of not mon than five hundred dollars 1$5001.
❑ I,as owner progeny,or my employees with wagon as BACK FLOW PROTECT.DEVICE 4,00 OCC.GROUP RES.UNITS
(S
their sole compensation,ation,will the work:and the structure is not
intended or offered for sale (Sec. 7044, Rosiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:1'11e Contractor's License Law does not apply to an owner of
Property who huilds or improves Nercon,and who does such work FIXTURES,PER TRAP 5.00 S6FT.FLOORAREA TOTALACREAGE
himself re through his own employees,for sale.Provided that such improve. -
miniproenoall is old or wthinone yearof completion the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 A/\ IP_�
or improvement is sold rdea o line year hacompletion,the owner- GAS-EA.SYSTEM-OVER 4(EA.). 2.00 `-'1L•l lD
prove
p have the harden of proving that he did not build or int- BUILDING USE
prove fors owner ofsoled. - INDUSTRIALWASTE INTER. 30.00 RES IND CON PB ''enter
'❑ I,as owner of Ibe property,um exdusivdY cont'xding with ❑. 0 11 o El
licensed contractors m construct the project (Sec.7044,Business LAWN SPRINKLERS-Il INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code:'I'lie Contractor's License Law docs not apply _
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ;
contracts for such projects with a conlractons)licensed pursuant no SEWER-SANITARY-STORM EA.200ft/10.00
the Contractoiv License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,It kl'.C.for l his WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSA"FION DECLARATION WATER TREATING EQUIP. 5.00 .
1 hereby affirm that I have a certificate of consent to self-insure. ZONING. ENG.SITE NO.
or a aeo Pirate of Workers'Compensation insurance,or a eerlified
copy thereof(Sec.360 ab.C.). ^,�, - • -
I'ala:y No. umpany_ 0d.
0 ❑ Certified ' s1,ereb urnis y{ FIRE$PRINK ENERGY T-24
z Z ❑ Certif ��pOy is f��1/ itl inspection division. MISC.- REFER TO ORD. E] � E]
p A 0 Ce a -l- - V N Y N
~ rn PERMIT ISSUANCE 10.00
• - CIiR IPICATIi OF li%F IP' (1N FROM WORKI!RS' FLOOD ZONE A.L.U.C.
UJ COMPENSA 10 INSURANCE PLG.CONTR. ❑C.NO. PLG.
n' 0 11'his'soction need Hill he e_ompletet if the punmil is dill one TOTAL V❑ N[D Y 0 NO
� Z u hundred doll xrsfs 100)or less)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I'•xhall not emmm
ploy any person in any arur an as to
O L)become subject to the Workeri m
Copensation Laws of California - -
Dam Applicant ALTER OR ADD TO MECH. . 5.00 BUILDING
} N NOTICE,'ID APPLICANT: If,after making this Certificate of Ex-
,r ? emption,you should become subject m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tlm Labor Code, you ,oust forthwith comply will, - FEE
CJ such provisions or this permit shah he deemed revoked AIR HANDLING UNIT(TO 10=CF.M.) .4.00
-` CONSTRUCT ION LEN DING AGENCY AIR HANDLING UNIT(OVER IQOOOC.F.M.) 6.00 ,SEISMIC FEE �-
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Cie.C.). 11� � HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Add, l! HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address 'ELECTRIC u
•1 certify that I have read Ods applical inn and state ilia(the above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city and county PLUMBING
ordinances and stale laws (elating to building construction, and BOILER-COMP(3H.P.or 100,000 B.T.U.L,6.00
hereby authorize 'representatives of this city es enter upon [he BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes,
(We)•agree to save, imemmd'y and keep harmless the City of MISC.- - REFER.TO ORD.
Cupertino ugains abilities,ju mhents, co and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any .accrue mins said CI in consequence of the
granting f permit. MECH.CONT. LIC.N0. MECH.
TOTAL
� w�•!TI I TOTAL
Signatu of Applicant/ onlract Dale
A.
OFFICE COPY,