5451 (2) `APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
FAME
NG PROJECT IDENTIFICATION APPLICATION & PERMIT
I.L. , 1NG ELECTRICAL-PLUMBING-MECHANICAL 5451�/ !i :gi1PLAN CHECK VALIDATION
ELECTRICPERMIT FEE
s• ad Al DNEUTLETS-SWITCHES-RECEP 5.00/1.00
uc.No, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PRONE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS B 00 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
AOImEss ENG. SPECIALCIRCUIT '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APvucANrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o a• LICENSED CONTRACTORS DECLARATION
a:v 4 1 hnereby affmthat I mn licensed under provisions of Chapter 9 ISSUANCE DATE
v,va w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect.
z o u, - LuvH,c Class Lic.Number ❑ ❑ 0
0 m r w Dale Cmstractor
¢ m s BUILDING PERMIT
a a a OWNER-BUILDER DE.CLARKITON i1NFORMAT(ION
X 3 LL N I hereby affirm that I um exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
t-.. o¢ Law for the following reason.(Sec.703L5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city orcounty which requires a permit to construct,alter,
¢Q p improve,demolish,or repairany structure,prior to its issuance,also ELEC.CONTO LIC.NO. ELEC. -
O C requires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO
x m he is licensed pursuant to the provisions of the Contractor's License �7
_ii
Law(Chapter 9(commencing with Section 7000)ol-Division 3 oflhe - l/.7�rsQ,
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE'
fe F$ the basis liethe alleged exemption.Any violation of Seclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a pernat subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).)'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 occ.Group RES.UNITS
their sole compensation,wdl do the work,and the structure is not
intended Or offered for side (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:property
h o builds os License 1-ace dues not apply loan owner of
himself or
builds his improves who does Such im work FIXTURES-PER TRAP 4.00 sD.Fr.PLooR AREA TOTALACREAGE
himself or through his own employees,provided that such im building
aunts are not intended or offered lot sale.If,however,the M1uilAing GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden ofproving that he did not build or HIT. GAS
IND CON PB Dinar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. - ' 0.00
LII,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ 1:1licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS• 1 C 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor i License Low does not apply i
to an Owner of property who builds or improves thereon,and who LAWN SPRINKLERS-C101115"_!10,
con Hurls forsuch projects with a contractm(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-ST M EA. ft/6.0 TRACT NO. - PARCEL NO.
❑ Izinc exempt under See. ,B.&P.C.In,this WATER HEATER W/VEWV Ot CUpgrt1hpo
reason
Owner Date - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKIiRS'C I'ENSATION DECLARATION WATER TREATING EQUIP. 4.00
I herehy aliirm that I have a canificaofconsent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company -
Q- ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is riled with (he city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
CERTIFICATE OF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL r� Y❑ No Y❑ N❑
� Z IT undred dollars IS 100)or less.) ' 54 („sp - y"A{N ., s �.: y
U O 1 certify that in the performance OI'the work I'ur which this pc . $' 'jY116f"Yi 'S LTE FEE SUMMARY
OTY 'q INECHANICALIPERMIT $y,' I,. FEE t [,a
LL P mil is VoHmd,I shall not employ any person in any manner so as to p ._qM' ? 'j r% 'k}'tj
U become subject to the Workers'Compensation Laws of California.
UJ Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making'this Certificate of Ex.
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
(.7 such provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10j000CRIM ' 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101)00CEM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a,construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of(he work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name H EATING UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and slate that the above - VENTILATION FAN (SINGLE) 3.00 0-9
information is correct.1 agree to comply with all city and county PLUMBING l V
ordinances and stale laws relating (o building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of (his city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP(Over 1011,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD:
Cupertino against liabilities,judgments, costs and expenses which - CONST.TAX
may in any way accrue against said City in consequence'of,the PERMIT ISSUANCE 3.00
guano of(his peimil. MECH,CONT. LIC.NO. MECH. P ,
Al
TOTAL , TOTAL�r �'-
rgn ore of Applicant/Co actor Date
OFFICE COPY - _
r'
I
CITY OF CUPERTINO OCFFFFIICE _
GAS SERVICE NOTICE
1 9ke
To
Ycu are hereby authorized to connect the GAS service for !'
Owner or Tenant C`—L<,.rL�/.( �,�•/7ix/�,--f...�,.� i
At_L�O/d S— �fn r G /1L � 1Jf l
. .. ,j New Service ••
No. of Meters Reconnect ,
No. of Add. Meters Move Service
' Move Meter
7 � I
PLUMBING INSPECTOR
t - _ utt 0
1 1