5712 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY "
BUILDING PROJECT IDENTIFICATION ' PERMIT NUMBER
BUILDING
aoonlss APPLICATION & PERMITBUILDING ELECTRICAL—PUMBING—ME
CHANICALgex=4 TA
OWNER'S - - PLAN CHECK VALIDATION
5712-
NAME � + � � DTV. • ,ELECTRIC PERMIT FEE
/�LA4SGfQ�. PX
BE
-
CONTRACTORS .
UTLETS-SWITCHES-RECEP 5.00/1.00 '
545 uc.No, y yf�rf LIGHTING FIXTURES 5.00/1.00
-6-0,Te (/ nooessTORSnPPLIANCES-RESIDEN
TIAL . 4.00
PANELS 5.00 7 DATE OF APPLICATION ORCXrtECT PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
ENGINEER
LIC.NO. � SIGNS TRANS. 3.00ARCH OR '
ADDRESS ENG, - SPECIAL CIRCUIT '5-DU PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. t 15.00 &CATE
APPLICANTS ADDRESS MOTORS s' 0 J SEE FEE SCH.SERVICE CHANGE .10.00O ' 'LICIiNSED CON'I'RACI'ORS UECLARA'I'IONis u 1 hereby_uffum that I nm licensed under provisions ofChapter 9m ommencing wish section 7000)nT Division 3 of the Business andE E PLGMECH.
r m y I'rofcssions Code,and m license is in full)Tnnd cf Pct ' -� ❑
p i w nil`
License Class_G� C Lic.Number YY -
w L w Uatn_ .1 Crintractor
¢ y
¢ ¢w a OWNER-IfUPFIiR DECLARATION BU DING PERMIT
° o - MISd.— - INFORMATION '
X g w a '1 hereby`affirm that I am exempt from the Cmttructor's License REFER TO.ORD
a- 0 4 Law for the following reason.(Sec.7031.5,Business and Professions VALUATION - S/FT:
- g .PERMIT ISSUANCE 6.00
Code:Any city or county which requirese permit to is isma construct, also
¢ ¢ ¢ 0 improve,demolish,Dr repair any structure,prior In its'issuance,also ELEC.CONTH. LIG NO. ELEC.
al -0 ¢ requires the applicant for such permit to file a signed statement thatTOTA
A w m m Ice is licenser)pursuant to the provisions of the Contractor's License ERMIT TO
F z a Law(Chapter 9,4commencing with Section 7000)of Division 3 ofthe - .r
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE.
¢ r- o the hasis for lite alleged exemption.Any violation ofsection 7031.5 STORIES TYPE CONSTR.
dam' by�rry applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN'& VENT-WATER (EA.) 4.00
o(nol more than Five hundred dollars(55000.):
❑ 1,as owner of Iht property,or my employcus with wages as
their soBACK FLOW PROTECT. DEVICE 2.00 OCC,GROUP BEs.UNITSle Compensatimt,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: The Contractor's License Law does not apply to an owner of
properly who blind&or hapolves flacon,:rad who does such work FIXTURES-PER TRAP - - ,4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
'� himself or,through his own employees,provided that such improve-
h Hunts are nal intended or offered fill sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 -
or improvement is sold within one year of completion,the owner- GAS-EA:.S
bolrlur will have the huiden'of,proving that he did not build arSYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
am- _ .
prove for purpose of sale.). " :( INDUSTRIAL WASTE INTER. 20.00 Es I❑ . ❑N PB❑ Other❑
❑ 1,as owner of th
e property,am"elusively contracting with - -
licensed contractors to o strum the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and I'mNssium Cntle: I lar ConTaclar's License Law Anes not apply -
to an owner at properly who builds or improves Ihereon,'and who LAWN SPRINKLERS-OVER 5(EA.) - 1.00 -
contracts for such projects with a contracloos)licensed pursuant to - -
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 , TRACT NO. PARCEL NO.
rcasonLnm exmnpt under Sec. ,II'&I'.C.till this WATER HEATER W/VENT 4.00 '
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
. WORKERS'COMPENSATION DIiCLARA'PION WATER TREATING EQUIP. 4.00
I hem by affirm that I have o certificate ofconsenl to self-insure,
or a'cnrtificale of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lub.C.). -
I'ulicy No. - Campmiy
(] ❑ Certified copy iss Filed fwith the -
z Z 0',Certified copy if fled with the city inspection division. FIRE$PRINK ENERGY TQC
FO Applicant MISC.- REFERTO ORD. y YE] NF ,v No
fi=r CFR"I'IIICATI:Op EXEA1PTIONI:ROMWOI(KERS- PERMITISSUANCE 6.00 FLOOD ZONE A.L.U.O.
W D - COMIPENSAIION INSURANCE PLG.CONTR. LIG NO. , PLG. -
Z (This sc cluin need not be Completed if flit permit is far one _ TOTAL Y❑ N� Y E) NF1
hundred dollia,1$1000pr less)• _ -
U O I ceHify that in the performance of the work f which Otis Per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,1 shall not employ un perSo y Hunner so as to
L) - hccnmc sub'kat tq lh orkms'C t m n aws of mit. -
a Uatc_7_ fr(f pPlicunt. - .BUILDING,
NOTICE TO AI'P ICAN'P: I ,atter making this Cerlificme of fix-, ALTER OR ADD TO MECH: 4.00 _
F.? emption,'you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK '
provisions of the Labor.Code, you must forthwith comply with FEE
U Such provisions or this permit shall be deemed revoked. . AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LINUING AGENCY AIR HANDLING UNIT(OVER.10=CRM.) 5.00SEISMID,FEE
I hereby:uHhnn.thai there is a Construction trading agency for EXHAUST HOOD(WITH DUCT) 2.00 -
, the performance of the work for which this permit is issued fsec. MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name'- H EATI NG U N IT(OVER 100,000 B.T.U.)7.50
' Lender's Address ELECTRIC -
Icerlifythallhavereadlhisapplicimn and stale that the above VENTILATION FAN (SINGLE) 3.00
mfor radian is correct. I agree to comply with all city and countyPLUMBING
olmances and state laws relating to building Construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 - I -
r"�� ,covey authorize representatives for ins of this city to muco upon dee BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL -
,, above-m entioned propertyforinsp of this
purposes.
(We) agree to sav- 'ad call fy'and keep harmless the City of MISC.- REFER TO ORD:
Cupertino against obi lies,judgntoiUs$cauls and.axpensca which 'PERMIT ISSUANCE 3.00 'CONST.TAX
may in any_w accr a against said City'in consequence o1'the '.
gran l ¢ CA ,r MECH.CONT. LIG NO. MECH.
f) ✓//L� y3-f1 TOTAL TOTAL
(r Signa re of pplicant/Conimctor Date
- - OFFICE COPY '