4375 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY
BU LDI NO PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT - A
ADDRIt f{
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PL CHECK VALIDATION
NAME �//]��ry�(s QTY. ELECTRIC PERMIT FEE pAI�
Qa?S3 66
y NAMtERAcrDRs UTLETS-SWITCHES-RECEP 5.00/1.00 f3 'j983
X LIC. LIGHTING FIXTURES 5.00/1.00
/ .DN Ac7oR's G/ ` PPLIANCES-RESIDENTIAL 4.00 Of Capervino
ADaREss iii-'l
Z pry - OZ PANELS 5.00 CITY DATE OF APPLICATION
ARCHITECT SIGNS S.DG
ENGINEER PLAN CHECK FEE P.C.NO.
OR
-
LIC NO SIGNS TRANS. 3.00
ARCH
.OR ENG. VAt•IDATIO
AESS SPECIAL CIRCUIT 5.00 111111` `/
ZIP EMP.METER OR POLE INS. 15.00 �/1 7
APPL MOTORS SEE FEE SCH. (�
ADDRESS
ss �Q IJ
SERVICE CHANGE 10.00
EF o LICENSED CONTRACTORS DECLARATION
a u w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H (commencing with Section 7000)of Division 3 of the Business and
Q 0 ^ DG. ELECT. PLG.-
a_ MECH.
y, n i Professions Code and my license is in full fore•:and c Ice ' 0..
A i m a License Clas - i itr- Numb,
r m r j Datc Conac
Q y E � tJf S/B C r O N L Y BUILDING PERMIT
¢ ¢ Q OWNER-BUILDER DECLARATION
A o a u INFORMATION
w ; LL w 1 hereby infirm that I :I,,,exempt from the Contractor's License MISC.- REFER TO ORD
Fu. DQ Law for the following mamr.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION�f//�/ '$/FT.
y0 Code:Any city or county which requires a permit to Construe(,alter,
//�V
¢ 2 Q 2O improve,demolish,or repair any snocune,prior to its issuance,u.s0 ELEC.CONTR, LIC.NO. ELEC:
"„V��
d W m LL require,Ile applicant for He,,pormlt to file n signed statement tllal TDTAL PE TO
he is licensed pursuant to the provisions of tire Contractor's License
F Z i Law(Chapter9(commeneingwith Section 7000)0(Division 3 ofthe r
Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
sio
¢ f m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES Tv E CONSTR.
a ; � by any applicant for a permit subjects the applicant Ion civil penally ALTER-DRAIN& VENT-WATER (EA.) 4.00 l
of not more than five hundred dollars($500).): l
4a JJ
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC GO ES.u RS
their sole conhpensation,will do the work,and the structure is not
intended or offered for .to (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
propL•rty who builds Or Improves'thereon,and who dOCS such work FIXTURES-PER TRAP 4.00 S0.FT.FLOOR AREA TOTAL ACREAGE.
himsel(or through his own employees,provided that such improve-
centsamnotintendedorofferedforSale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or improvement Is sold within one year of cnmplet ion, 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 an-
prove for purpose of sale.). RE IND CON PB On.,
I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
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 an owner of property who builds or improves thwvon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forns LicenecLwithacontruaorfsl licensed pursnmm¢l - SEWER-SANITARY-STORM EA.200ft/8.00
the Cactsfo such
License Law. - TRACT NO. PARCEL NO.
❑ Iumcxemplundcr Scc. I,B.&P.C.I'or lh''s WATER HEATER W/VENT 4.00
reason
Date owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKBRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby uffina that I have u certificate of consent to self-insum, ZONING ENG.SITE N0.
1 / or a certificate of Workers'Compensation Insurance,or a"trifled
�(
copy thereof(Sec.3800,Lab.C.).
Policy No. Company_
Q ❑. Certified copy is 1, eby to nis - / - FIRE SPRINK ENERGY T 24
z Z ❑ 'Certified I .ed t1 l inspect' division. MISC.- REFER TO ORD.
Q Applicant' Y ❑ N[] Y N[3
CC CFRTIFICATEOF EXEMP FROM WORKERS' PERMIT ISSUANCE 6.00 FLooD ZONE A.L.u.c.
W COMPIiNSAI'I SURANCE PI.G.CONTH. LIC.NO. PLG.
IL O (This section need not be cr pleled If the permit is fill one TOTAL V❑ N❑ V ❑ . N❑
Z) Z hundred do11ars($Ie-0)or less.)
U O. I certify that in the performance ol'the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
l.L I- mit is issued,1 shall not employ any person in any manner so as to
O W recono subject to tire Workers'Compersulioo Laws of California
Date-Applicant BUILDING
d ALTER OR ADD TO MECH. 4.00
} m NOTICE '1'O APPLICANT': If,after making this Certificate of nix- -
� Z empIion,you should become subject to the Workers'CaTiNusation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby'affirm that there is a construction lending agency fir EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is Issued(Sec. MICROFILM
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NamAddress
HEATING UNIT(OVER 100,000 B.T.U.)7.50 '
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Information is cofrecl. 1 nine, to comply will, all city and county PLUMBING
ordinances and stale laws relating to building construction, 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 (Over 100,000 BTUI 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 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra of this permit. MECH.CONT. - LIC.NO. MECH.
%__ TOTAL TOTAL
gnetmm of APp Icart Contract Dae r
OFFICE COPY