18093 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT-PEN ONLY
eUl LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
L
APPLICATION & PERMIT
anIDINO
ADDRESS ELECTRICAL—PLUMBING—MECHANICAL• q O93
BUILDINGe
OWNER'S PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE •�'f -I�/ `/r
CNAMEONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
_ Svs✓O iL' LIC.NO. 4/S-10) S—V LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS e`66iia•-T+3 APPLIANC ES-RESI DENTIAL 4.00
PHONE 3r6�os PANELS 10.00 DATE OF APPLICATION
OR
- PANELS(OVER 200 AMP) 20.00 ' PLAN CHECK FEE P.C.N0.
RR
ENGINEER
- uc.NO ISIGNS TRANS. 3.00
ADDrmSS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S C
ADDRESS ? - MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 -
w o O LICENSED CONTRACTORS DECLARATION ���•
a i w [thereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business and SUANCE DATE
BLDG. ELECT] PLG. MECH.
r• w a, Professions Code,and my license Is in full forge and effea. J U ❑ ❑ ❑
Z0 m o License Class Lie.Number-- S -
r w H a, Dare Contractor.','// '
¢w OWNI-.R-BUILDI:R DECI-A , TON BUILDING PERMIT
X ;LL y I hereby affirm that I am exempt from the Contractor s License MISC.— ORD INFORMATION
F m o J Law for the following reason.(Sec,7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requiresa pennit toconstrmt,aller,
QQ¢ Improve,demolish,or repair any structure,prior to Its issnall Cc,also ELEC.CONTR. LIC.NO. ELEC.
o¢ rcqumes,the applicant for.such permit to file a signed statement that TOTAL
u w m�` he is licensed pursrmnt to the provisions of the Contractors License PERMIT TO
La Low(Chapter 9(commencing with Section 7000)of Division 3 of the
i et Business and Professions Code)or that the is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ F m the basic for the Illlcged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ;� by any applicant for a permit subjects the applicant toacivil penally ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(8500)):
❑ I,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 do the work,and the structure is not
intended,or offered for sale (Sc,. 7044, Business and Prolossions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
N• y Cade:The Contractor's License Law does not upply to an owner of
property Wl[o builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA -TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are,not intended or offered for sale.If,howevee the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
e Or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
�E1 builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
CII,'as owner of the property,am exclusively•contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec!7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 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 contractoos)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec.—,B.&P.C.for this
reason WATER HEATER W/VENT 8.00 '
Owner Date WATER SYSTEM. 5.00 ACC.OATE ACC.FILE NO.
W'ORKE RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirin that I have a certificate of consent to selM1insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG:SITE NO.
copy thereof(S 3800,Lab.C). -
Po'cy Company
O ,
ertified copy is hereby furnished. FIRE SPRINK ENERGY T-24
z Z ❑ Certifi copy is.fit If col If t 'ity inspection_livision.
O Apple"nt (! - MISC.- REFER TO ORD. v0 N[_ v � N�
~ rn �— PERMIT ISSUANCE 10,00
cc — 'CERTIF 'ATF O ;XEMPTION FROM'WORKERS' PFLOOD ZONE 'A.L.UG.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. -
CL ❑ tlhis section meed not be completed if the-permit is for One TOTAL ' Y NE] Y F] NC]
D Z hundred dollars(S100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is-issued,I shall not employ any person in any Iran net so as to
O W become subject to the Workers'Compensation Laws of California.
C. Date Applicant BUILDING
>_ 0NOTICE TO APPLICANT: If,after making this Certificate of Ex ALTER OR ADD TO MECH. 5,00 5• Q O
H ? emptier,you should become subject m the Workers'Compensation APPLIANCE 5.00 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 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE OsV
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
The performance of ther
e work for which this prlit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT ER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
e 1 certify;that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information correct. I agretoocomply with all city and coumy PLUMBING
ordinances and State laws te to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.)- 6.00
hereby aulhoria representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
.✓ ,:+ above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. - -
"Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX,
may in my.way accrue against said City in consequence of the
ranting this erift. ( MECH,CONT. LIC.NO, MECH.
TOTAL TOTAL
Signature of ¢a c Or Uate ^+LSO
OFFICE COPY