18318 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED EINES - USE BALL POINT PEN ONLY
%s
BUILDING PROJECT IDENTIFICATION PEflMIT NUMBER
BUILDING _ APPLICATION & PERMIT. , 18318-1
ADDRESS % ( / BUI LOI NG - ELECTRICAL-PLUMBING-MECHANICAL }. �J I
Imo/
OWNER'S _ PLAN CHECK VALIDATION
"AmEMf QTY. ELECTRIC PERMIT - FEE . r
r PRONE - _`O -1-T-00
CONTERACTOR's 11 ' OUTLETS-SWITCHES-RECEP '10.0011.00 ,
IPA
5 Q
'IC.NO. LIGHTING FIXTURES - 10.00/1.00
CONTRACTORS I - p ' APPLIANCES-RESIDENTIAL, 4.00
A DREss �,of 7 4UN `
L/ 37 G PI N � ^ 91-1 PANELS . 10.00 ' OATE OF APPLICATION
ARCHITECT PANELS
EN '(OVER 200 AMP) 20.00 - PLAN CHECK FEE' P.C:NO.
OR _
GINEER//��f1,, 1
' SIGNS TRANS. - 3.00 i
AUDIT Ess EAG.' ' SPECIAL'CIRCUIT "5.00 ,•-n t PERMIT VALIDATION
IiIP EMP. METER OR POLE INS. "20.00 r/,BO
APPLI MOTORS - SEE FEE SCH: '��-Iff
ADDRESS - ! - �• ,
- - SERVICE CHANGE ;, 20,00. MM
f �'00 LICIiN51iD CONTRACTORS DIiGI,ARATION � y`V t�•'�e'
a z w I hereby affirm that I.anl licensedunder,provisions of Chapter 9 1111 8 ISSUANCE DATE
w G H (commencing with Section 7000)of Division 3 of the Business and
BLDG.. ELECT. PLG. MECH.-
t-y'z Professions Code,and my license is in full force and effect - ❑ ❑
o o o License Class I.ic.Number-
L)
umber - -
F ,Ai F J Date Cmllr'JetOf v• .1 City o^Yubho ^
ac ¢o AIIOM1¢ OWNLR-BUILDER DECLAR - - BUILDING PERMIT
a INFORMATION
y I hereby affirm that I am exempt from theConl actor's License MISC:- REFER TO ORD -
LL o a I-ilw for the following reason.(See 70315 Bu'messand PROBsdons - VALUATION $/FT.
_ PERMIT ISSUANCE 10.00 -
i
Code Anycty or county whl br I ies'Iperi lm onstruct,alteq - - -
pimprove,dcnuilish,or mpmra yamclua priorl its lance,also ELEC'CONTR. LIC!,NO. ELEC. ��`DO
o tt requires the applicant for Such permit to file a signed statement that - TOTAL
6 W m y he Is licensed pursuant to the provisions of life Contractors License t PERMIT TO
� zQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe eC
i o Business and Professions Code)or that he is Cxmnpl theretrom and OTY. PLUMBING PERMIT FEE if III b
H the haste for the alleged excnq!linn.Any vnhG inn,n(Secliim 7031.5 e 1 ISTORIE4 TYPE CONSTR.
n3�2 by any applicant for a permit subjects thenpplicant to a civil penalty
of not more than live hundred diAhn,(SSOOL): v ALTER-DRAIN& VENT-WATER'(EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will(to the work,and the structure is.not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOORROOFAREACON D. 5,00
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-.' 5.00 ' SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own mnpluyc�es,provided that such im,one- -
mems are not imcnded'or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
tr improvement is sold within one year of completion,the owner-
, builder will have the burden of proving that hC did nOPbuild Or int- GAS-EA.SYSTEM-.OVER 4 (EA.) 2.00 .BUILDING USE
prove for purpose ofsdeJ., • RES IND CON PB' •Other
❑ 1,as owner of the properly,am exclusively couracting with, INDUSTRIAL WASTE INTER. 30.00 E] E] E] ❑ .❑ .
licensed c.otractorS 1. construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Luatuve Law does not apply
to an owner Of property sell.builds or improves thereon,and.wim LAWN SPRINKLERS-OVER 5 (EA.) 1.00
s contracts for such projects with a contractors)licensed pursuant in
life Contractor's License Law._, - - SEWER-SAN ITARV-STORM EA,2010.00 .TRACT NO. PARCEL NO.
❑ lent excnmt under Sec`' ,B'.&P.C.fol tI;D WATER HEATER-W/VENT 6.00 `
reason
Owner Dale - WATER SYSTEM 5.00 - ACC.DATE ACC.FILE NO.
e•
WORKERS'CO.MPENSATTON DECLARATION r WATER TREATING EQUIP, 5.00
hereby atfinn IIIA have a ccrtificatc Of consent to sah�iosure,
it u certificate Of Workers'Compensation Insaranca,or u certified" - ZONING ENG.SITE NO.
copy 11 reof(Scc.3S00,Lah.C.).
I'olySea Company. - ..
Oedified Copy is hereby furnished.til 'T +FIRE SPOINK ENERGY T-24
Z Z ertifia >yy tiled with, thr city inspection Division. MISC.- REFER TO ORD.
O
Applicant '/!a•lh Y ❑ N❑. ." Y ❑ N❑
~•N PERMIT ISSUANCE '10.00
- CIiRTIIICATIi OP EXEMPT'ION PROM WORKERS' FLOODZONE A.L.U.C.
W > COMPENSA'IION INSURANCE r• PLG.CONTE. LIC.NO. PLG:
0.= 0 ' '('this section need not be completed if the permit is for one _ TOTAL V 0 N❑ Y ❑' No
.' hundred dollars IS 100)or less.l
L) O: 1 certify that in the performance Of.the work Ibr which this per- OTY. MECHANICAL PERMIT 'FEE FEE SUMMARY -'
ly I- mil is issued,I [fill not employ any person in ally manner so xs to
O L) become subject to the Workers'Compensaf ion Laws of Cah ou-lit.
y Datc Applicam - ALTER OR ADD TO MECH. •c 5.00 BUILDING
>- W NO'IICF•TO APPLICANT: If,alter making this Certificate of Ex-
? entption,you should become subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
p...... m, of fie Labor Code, you rami Ib Nllwith comply with
U q
suchprovisions or this permn duall be deemed revokedOD
. AIR HANDLING UNIT(TO 1QOC.F.M.) 4.00 - FEE -
CONSTRUCTIONLENDINGAGENCY AIR HANDLING UNIT(OVER 10,000C.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(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Node HEATI NG UN IT 100,000 B.T.U.)9.50 '7 •O`Q
Lender's Address - ELECTRIC o�
(,certify that I have read ilik application and state that the above. VENTILATION FAN (SINGLE) 4.00
information n correct.[ relati comply will all city and county
1 ordinances.and state lawss relining to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
I, by authori<c rcpreserlalwr, Of this-city to enter Bpcm the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless,the City of MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costs and exenses which PERMIT ISSUANCE 10.00 - CONST.TAX'
may in any way'accrue against said City in consequence of the
nmti f t71is pen li MECH.CONT. LIC.NO. , MECH.
/
TOTAL TOTAL .OD
Signature of Applicant ontractor Date
OFFICE COPY