4486 (2) APPLICANT TO FILL IN IN WITHIN RED LINES -.USE BALI. POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4486
� A 0 C
ADORE55 s Y�F(J U
S _ BUILDING'-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'a - PLAN CHECKVALIDATION
"AMB QTY. ELECTRIC PERMIT FEE
.PHONE
'cONTRAGTR's �J ^p _ OUTLETS
-SWITCHES-RECEP. 5.00/1.00
N ME _JJ O ..
lm.No. - LIGHTING FIXTURES 5.00/1.00
CONTRACTORS - �p3�LZ/ PPLIANCES-RESIDENTIAL 4.00
ADDREss Pte_
PRONE
IF
5.00 PATE OF APPLICATION
ARCHITECT - _ SIGN$, - 6.00 .PLAN CHECK FEE P.C.NO.
OR .
ENGINEER
. . uc.No. SIGNS TRANS. '� 3.00 `
ARCH.DR ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP. METER OR POLE INS. 15.00
ADDRESS rs - .. t MOTORS .; SEE FEE SCH. \�7U"1►/JO
ADDRESS •. '
SERVICE CHANGE 10.00 �V//p/Cy
o o LICENSED CONTRACTORS DECLARATION- Q O•..)
a U 1 hereby affirm that I am licensed under pravisI'I of Chapter 9. ISSUANCE DATE
u (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. 'PLG. MECH.
�z Professions Co an�i license is in full force' cc El
z o w License ass Lic.Number 11
0 z r Uate Contractor
V
f >BUILDING•PERMIT- `
¢ , OWNER-BUILDER DECLARATION ----.- : 'INFORMATION:`' '
wr I hereby affirm that 1 am exempt from the Contractors License MISC.- - REFER TO ORD -
uoa Law for the following reason,(See.7031.5.Business and Professions PERMIT ISSUANCE 6.00
VALUATION $/FT.„
� - Code:'Any ci[yo[county which requiresa permit to construct,alter, ,
BS s-Be 0 Improve,demolish,at repair any structure,print 10 Its Issuance,also ELEC.CONTR. - LIC_NO, ELEC.
a
O u requires the applicant for such permit to file a signed statement that _ TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractors License
Hz >
Law(Chapter 9(Commencing with Section 7000)ofDivision 3 of the - - ������ ���
a Business and Professions Code)or that he is exempt therefrom and QTY. - PLUMBING PERMIT, _ FEE
r the basis for the alleged exemption.Any violation of Section 7031,5 STORIES TYPE CONSTR.
a ; $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500L):
❑ I,as owner of the'propetiy„or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 - OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
` intended or offered for sale fSec. 7044, Business and Professions DRAINS- 4.00 `
Code:The Contmetor's License Law does not apply to ail owner of '
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.PT:FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner . .) 1.00 BUILDING USE
GAS-EASYSTEM-OVER 4 IEA
builder will have the burden of proving that he did not hard or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTEINTER. - 20.00
❑,1,as owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensed contractors to construct tile Pincer(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dries not apply
to an owner of property who builds or improves 1Lemon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to - -
the Contractor's License Law. SEWER-SANIY-STOR OOft,L o TRACT NO. PARCEL NO.
❑ I am exempt under Sec ,BAP,C.for this WATER HEATTARER W/VEN 4.00
reason
Date Owner WATER SYSTEM .00 ACC.DATE ACC.FILE NO.
WORKERS9COMPENSA'1'ION DECLARATION WATER TREATING P. .00
' 1 hereby affirm that I have a certificate of consent io self-insure, _
or a certificate(if Workers'Compensation Insurance,or a certified ZONING ENO.SITE NO,
con t thereof(Sec.36009 Lab.C.). //ll��
Ci
Policy N.. Cine yTe
Q ❑ Certified copy ishereby furnished. �'-� FIRESPRINK ENERGY T-24 .
❑ Certific cop is filed with rhes city inspection division. MISC. R FERT ORD.
Z Applicant Y ❑ N❑ V ❑ N❑
CC m CE FICAT80F F,XF MPTION F M WORKERS' PERMIT ISSUANCE 6.00 FLOOD'ZONE A.L.U,C.
W > COMPENSATION INSURANCE PLG:CONTR. LIC.NO. PLC. pp
CL 0 (This section need not he completed if the Permit is for one' TOTALZ.6 �� Y ElNEI
Y E] N❑
D Z hundred dollars($100) I I I '
U O 1 certify that fit the performance of the work for which this per- QTY. -MECHANICAL PERMIT - FEE -'FEE SUMMARY
IL F- mil is issued,1 shall not employ any person In any manner so as to - -
U become subject to the Workers'Compensation-Laws of Cu111'ormiu.
W
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING .
} to NOTICE TO APPLICANT'. If,after making this CeIrficale of Ex- - -
F.. Z 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 10)D000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10k[WC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 .
the performance of the work for which this permit Is issued(Sec. MICROFILM
3097,Ce C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UN IT,(OVER 100,000 B.T.U.)7.50
LenderAddress ELECTRIC
I certify that I have read this application and state fiat the above VENTILATION FAN (SINGLE) 3.00 go
information is correct 1 agree to`comply with ull city and county PLUMBING Q
ordinances'.and state laws"relating to building onstruct or,and BOILER-COMPI3 H.P.or 100,000 B.T.U.)'4.00
hertby anthOTIZE.Ceparesentatives 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,jAgments, costs and expenses which CONST.TAX
may In any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
gr' ng of this peau' MECH.CONT. - LIC.N0. MECH.
TorAL TOTAL
Igna eof pplicanl/Contmeam Date
.. OFFICE COPY