4398 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES - USE BALI. POINT PEN ONLY
BU I LD INGPROYECT iDENTI FICATION _N PERMIT NUMBER
(� BUILDING APPLICATION & PERMIT I (� 8
(_ AooREss J v
S �G I&Zu BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWrvER's - -t -
PLA 10 LIGATION
" //' _ •^� CITY. ELECTRIC PERMIT FEE !Y
L ���/1/IPHONE.7J 7 ICTCn
I� CONTRACTORS (Jf�r 30 1Qv;
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
:.IC.NO. LIGHTING FIXTURES 5.00/1.00
nooness'ops PPLIANCES-RESIDENTIAL 4.00
-City Of CU O
perfin
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
moo ESS END
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCR.
APPLICA
SERVICE CHANGE 10.00
00 LICENSED CONTRACTORS DECLARATION
u ri 1 hereby affirm that I am licensed"odor provisions of Chapter,9ISSUAN ATE
mzIconon encing with Section 7000)of Division 3 of the Business and
a y BLOC. ELECT. G MECH.
H m Z Professions Cole,and my license is N fid)once and effect. El 1:1 ❑
Z o m - License Class Lic.
' @ m r� Date Qnllrncf ract.o or
a x 4 -+ BUILDING FFERMIT
O n o OWNER-BUILDER DECLARATION INFORMATION
w ; LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO OR
HLLOA Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 600 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
QQ Q 0 Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.Ni ELEC.
- u roquiresthe applicant for such permit to Rte a signed statement that TOTAL PER
TO
n w m he is licensed pursuant to the provisions of the Contractor's License
H Z ¢ Law(Chapter 9(commencing with Section 7000)of Division 3 of the
DTV. PLUMBING PERMIT FEE
i O Business and Professions Code)or that he is exempt therefrom and
M r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES YPE CONSTR.
by anyapplicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).1:
0 I,as owner of the property,or my employees will,wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES,UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
qP himself or through his own employees,provided that such improve-
ments are not intended or offered for safe It,however,the building GAS-EA.SYSTEM-11 SIC.4 OUTLETS 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 of proving that he did not build or im-
provefar purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 IND CON PS Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ El ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
In trclsclorh censeprojectswith a conUraclot sl licensed pursuant to
the nUraor s's LiceSEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELNO.
s se LLaw.
re p
Iarcpt BP
n pt mdcr c .C.hu❑Iis WATER HEATER W/VENT 4.00
s
o,(a o'er"" WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
N'ORKFiRS'COMPE SATION DECLA KA"fION WATER TREAT( QUIP. 4,00
I hereby affirm that 1 have a certificate of consent W self-insure,
or a certificate of Workers'Compensation Insurance,or a certified �- E� uC ZONING- ENG.SITE N0,
copy thereof(Sec.3800,Lab.C.l.
Policy No. - Company -
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 13 Certified copy is filed with the city inspection division. M C.- REFER TO RD.
O Applicant Y ❑ N C] Y ❑ NE)
~ rn PERMIT ISSUANCE 6.00
Cc - CIiRTIPICATIi OP IiXEM11PTION IrROM WORKIiRS' FLDOD ZONE A.L.0 c.
W COMPFNSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
CL Z I'I'his'section need-not be completed If the ❑permit is for mro TOTAL Y 'NE] Y ❑ NE]
hundred dollars IS 100)or less,)
U O' 1 certify that in the performance of um work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
O w become subject to tine Workers'Compensation Laws of Califorma. '
Ill Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
,� 2 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 shalt be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 3.00 -
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I 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 fSec. MICROFILM
r 3097,Civ CA - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I cent, shat l hove read this application and stole fiat the above VENTILATION FAN (SINGLE) 3.00
ordinances n correct. I agree to comply with all city and county PLUMBING y VY
ordinances and state laws relating m building co city
laid co and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP.IOver 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes,
(We) agree to save, roleomify and keep ,armltss the City of MISC.- REFER TO ORD.
Ise gain
liabilities,judgments, costs and expenses which - CONST.TAX
may in y way a rue wit City in conse9ucace of the PERMIT ISSUANCE - . 3.00
g' thisI MECH.CONT. - LIC.NO. MECH.
d TOTAL TOTAL E''V
gnaluF of A p icaut/ mractor Jute O
OFFICE COPY
` 1 C
' BUILDING INSPECTOR'S OFFICE
Bldg,Dept,
CITY OF CUPERTINO Office Copy
❑ Backflow Device Sanitary Permit No. / 3
❑ Sewer Connection Plumbing Permit No.
Plumbing Final Lot No.
t
Owner or Tenant z'A •� ✓����-�+ .�
At 5- .
Tract
' y
Date Connected -7 19 Date Final 14- 27-- 19f i -
j PLUMBING INSPECTOR