7286 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 3 9 S Sr�J) 'R*4 DO
�d BUILDING — ELECTRICAL—PLUMBING-MECHANICAL 7286
�f PLAN CHECK VALIDATION
!` "NME �fM1BK 86 �s3 QTY ELECTRIC PERMIT FEE
1.ON
CONTRACTORS - UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO, LIGHTING FIXTURES 5.00/1.00
ADORESE ORS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 1 DATE OF APPLICATION
OR•ROHITECT SIGNS 6.00
PLAN CHECK FEE P.C.NO.
- -
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. I PERMIT VALIDATION
ADDRESS ' SPECIALCIRCUIT 5.00
t zIv EMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS I '-
SERVICE CHANGE 10.00 /
in BE
F O o LICENSED CONTRACTORS DECLARATION
¢ v I heoby flirm rival I am licensed under provisions of Cha ter9
y a N (conmten ng with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r D z Professions Code,and my license is in full force and effect BLDG. ELECT. PLG. MECH.
o z m o Licensu Chas Lic.Numhcr
Dale Cumraclor
Q y F J
¢ ¢w a OWNER-BUILDER DECLARATION BUILDING P,E IT
R 0 A " MISC.— REFER TO ORD' INFORMATION
X g w r 1 hereby affirm that I am exempt from the Contractor's Licence
F w o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requires permit to construct.alter, 6.00
SEE,a a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC_
o¢ requires the applicant for such permit to file a signed statement that TOTAL
A w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
z o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
E r o the basis for the alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally
of not more than five hundred dollars(8500).): ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ I,as owner of nm property,or my employees with wages as BACK FLOW PROTECTDEVICE their Sole compensation,will do the work,and the structure is not . 2.00 OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4,00
Curie:Tire 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 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.4OUTLETS 4.00
or improvement is sold within one year of completion,lire owner- GAS-EA.SYSTEM-OVER 4 EA.)
builder will have the burden of proving that he did not build or im- ( 1.00 BUILDING USE
prove for purpose of sale.), I INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSE55ORS 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 E 1.00
contracts for such projects with a contmctorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM R/B.00 - TRACT NO. PARCEL NO.
❑nl um exempt ower Sec. ,B.&P.C.for raiz WATER HEATER W/V400
OwENner D e WATER SYSTEM .00 ACC.DATE ACC.FILE NO.
WORK F.RS'COS1PENSATION DECLARATION WATER TREATING EQUIP,
1 hereby affirm that I have a cereificate ofconsent mself-insure,
or a certificate of Workers'Compensation Insurance,or a certified —'-' ZONING ENG.SITE NO.
copy t hereof(See.3800,Lab.CJ.
Policy No. Company ^
O ❑ Certified copY'is herebydurnizhed. a T� FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with the city inspection division. r
F' O Applicant - MISC.- EFER TO ORD.— Y O NEI Y O IN
to CERTIFICAi'1:Of:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 t.� FLOOD ZONE A.L.U.C.
Lu > COMPENSATION INSURANCE � PLG.CONTE. LIC.NO. PLG.
CL (This section need not be completed if the permit is for one TOTAL Y O N Y 0 N 0
Z hundred dollars IS 100)or less) El
L) O I certify that in the performance of the work for which this per- GTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California.
Q. Datx Applicant ALTER OR ADD TO MECH. q,pp BUILDING
} f0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
� Z emption,you should become subject to the Workers'Compensation qpp LI
4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A000.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.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(Sec. MICROFILM
Leade3097,r's Nam � HEATING UNIT(TO 100,000 B.T.U.) 4.00
Leader's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL `�
(We) agree to save, indemnify and keep harmless the City ofLMECH.
MISC.- REFER TO ORD.
—9
CuPertino against liabilities,judgments, costs and expenses which
in an ace a PERMIT ISSUANCE CONST.TAX
gen n fY against said City in consequence of the 3.00
CONT. LIC.NO. MECH.
TOTAL TOTAL
gn [u o pplicant/Contractor Date
OFFICE COPY