The URL can be used to link to this page

09860 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES -'USE'BALL POINT PEN ONLY 7 BU I LDING PROJECT IDENTIFIC IN PERMITNUMBER AD DI DESS .� . APPLICATION & P IT 0 n 0 AOOH ESS b - .�:.. BUILDING —ELECTRICAL—PLUMBING —MECHANICAL NAly NERSLU/ (C��S' , Q[1 1 I �p PLAN CHECK VALIDATION QTY. lJ ELECTRIC PERMIT FEE PRUNE — , C iflACTOR3 �lO oZ OUTLETS 10.00/1.00 NA I _1 a'o .. 4 cm.No. I� L IGHTING FIXTURES 10.00/1.00 Lr CONTRACTOR'S r ADDRESS APPLIANCES-RESIDENTIAL 4.00 PANELS /T 10,00 ////^ L/ I D DATE OF APPLICATION rV) ORRcmTECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO. ENGINEER uc.NO. SIGNS TRANS. 3.00. ADDRESS ENG. SPECIAL CIRCUIT 500 ADDRESS � � PERMIT VALIDATION zlv TEMP.METER OR POLE INS. 20.00 APPLICANTS aooREss SEE FEE SDH. S 1 IMOTORS uO - SERVICE CHANGE 20.00 w m z 30.00 Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE . O" <u v 1 hereby alfinn that I nm licensed under provisions of Chapter 9 - ,.� sU ISSUANCE SATE H<H (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH. F w z Professions Code and my license is in full force and effect. zO L H o License as^ _ Lic.Numberap g7 ❑ ❑ ❑ r y r j Dec Lie N ctor_t�S--L��:: a ¢ w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT D INFORMATION w ;q w I hereby affirm that 1 um exempt frim the Conlr:¢for's License MISC.— REFER TO ORD u_ o¢ Law for lhefollovving reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE ,prM VALUATION . $/FT. 2 Code:Any city Dr county which requires a permit to construct.alter, 10.00 X ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIG NO. ELEC. LL requires the applicant for Such permit to file a signed statement that ` �:. I�G`Ii'�CGL [��1 TOTAL e. w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO F z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe FEE 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT /svl- the basis for the alleged exemption.Any violation of Scction7031,5 STORIES TYPE CONSTR. by any applicant for a permit subjects he applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 Of not more than five hundred vellum(S500).)i ❑ 1,as owner of he property,or my employees with wages as 00 BACK FLOW PROTECT.DEVICE 4. their sole compensation,will tlo the work,dad the structure is not OCC.GROUP RES.UNITS intended or offered for sale (Sec. 7044, Business and Professions INS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not imply to an owner of I property who builds or improves Ihercon,and who does such work FIX RES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE me!1h;Por through his own enged fors,provided eve such improve- mentsdre Getveluenntendedor withiared for If howevcq file the owner- GAS-E SYSTEM-1INC.4OUTLETS 6.00 or improvement Is sold within one your of completion,the owner builder will have the burden of proving that he did not build or im- GAS-EA. STEM-OVER 4 (EA.) 2.00 BUILDING Ust, / prove 1,aso neeose of tile.). INDUSTRIAL ASTEINTER. - 30.00 REs IND CON PB Other ❑ d as owner of Int property,am exclusively contracting 7044, u with � � ❑ ❑ ❑ licensed coigns od to construct the project ISec. 7044,Business LAWN SPRIN KL S-1 INC 6 V.B. 8.00 and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO. to an owner of property who builds or improves thereon,and who LAWN SPRINKLER -OVER contracts for such projects with a contractors)licensed pursuant to - the Contractor's License Law. 1 am exempt under Sec. for this SEWER-SANITARY-ST MEA.200ft/10.00 __TRNO. PARCEL NO. EI ,Ts reason WATER HEAT i PEC. ER W/VEN 6.00 Owner ,Date WATERSYSTEM- • S.00 ACC.DATE ACC,FILE NO. WORKERS'COMPENSA'rION DECLARA'FION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate ofconsent to self-iii or a certificate of Workers Compensation Insurance;or a certified ZONING ENG.SITE NO. copy there�(1' e'.3 Q0,Lab.C.). Policy NrV-G�L/nmpany 0 ❑ Certified copy is hereby furnished Z Z � Certilled P Is 01 It cit In edou division. EIRESPRINK ENERGYT-24 - F- O Alicant_. - �!', /!6�4 MISC, REFER TO OR , v N Y NE] y CISRTIFICATIi OP EXHMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 W COMPRNSATIONINSURANCIi - PLG.CONTR. LIC NO. PLG. FLOOD ZONE q.L.U.C., d O (This section need not be completed if the permit is for one TOTALY Is Y❑ N D z handfed dollars IS 100)or less.) 11 El � V O 1 certify that in the performance of the work for.which this per- CITY MECHANICAL PERMIT FEE SUMMARY UL U mil is issued,I shall not employ any person in any manner so as to FEE 0 W become subject to the Workers Compensation Laws of California. Ia. Dale AppliAPPLICANT I ALTER OR ADD TO MECH. 5,00 - BUILDING } In Date Ii TO APPLICANT If after making.this Certificate of F:x- Z emotion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK U suchlProvisionsions of s for his Permior t shall be deemeou inust d revoked comply with AIR HANDLING UNIT(TO 10 FEE . ,000CF.M.1 4.00 CONSTRUCTION LENDING AGENCY A HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EX HA ST HOOD (WITH DUCT) 500 the Performance of the work for which his permit is issued(S". . MICROFILM 3097,Civ.C.). HEATIN N IT(TO 100,000 B.T.U.) 8.00 Lender's Name Lenders Address - HEATING (OVER100,000 13 TUTU-)9.50 ELECTRIC' sso I certify that I have real this application and slate that the above VENTILATION F (SINGLE) 4.00 information is correct. 1 agree m comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.o 00,000 B.T.U.) 6.00 hereby anth0riee representatives of this city to enter upon the above-mentioned property for inspection purposes. I BOIL OMP IOvar 100,00 TUEE FEE SCH. MECHANICAL (We) agree to save,.indemnify and keep harmless the City of MISC. REI Sca 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 10.00 granting fit pe r. MECH.CONT. LIC.NO. ME TT TOTAL co'laramccuorpriali.I nntractor -- Uutc - OFFICE COPY ' r