6866 (2) APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD I NG PROJECT I DENTIFICATI ON PERMIT NUN
BUILDING APPLICATION & PERMIT - qq
A, REss.• BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Pr,�'6 S 6 6
%-13o S�Qov.y ILIA lvk '
NANER'S - PLAN CHECK VA IDATION
AME DTV: ELECTRIC PERMIT FEE V s ')v
ydV!vlUNJC.] •w•` � PRONE '
CDNTRAC'OR'S
OUTLETS-SWITCHES:RECEP, t;5.00/1.00 �gp01t1�
YS�YC� ��GMbTMA��r«o, LIGHTING FIXTURES ..'5.00/1.00
Lc
ADJIK VC ` . 4
ADDRESSk0YM` APPLIANCES-RESIDENTIAL .00
'
.9 \i 0 N O 't or q-1.61 HONE PANELS Y5.00 DATE OF APPLICATION
ARCHITECT 'PLAN CHECK FEE P.C.NO.
oR - SIGNS 6.00
NGINEER
LIC.No. .fib SIGNS TRANS. 3.00 '
ADDRESS ENG, t SPEGIAIL CIRCUIT 'S-DD PERMIT VALIDATION
ZIP EMP.METER OR POLEINS ,15.00
APPLICANT s MOTORS ., " SEE-FEE SCH.
A
{ SERVICE CHANGE - '..10.00 t I
00 o 'LICF-NSFD CONTRACTORS DFCLARAI'ION
ae La I hereby affirm that I am licensed under provisions of Chapter 9 r: I CE DATE
(commencing with Section 7000)of Division 3 of the Business and
<HBLDG. ELE PLG. MECH.
r w z Professions Code,and my license is in full force and effect.: `"O� ,❑ :❑
w W License Class Con Number
ractor
0 w H Datc Cnnlractor � rj . '
a r a / Li
�' BU LOING PERMIT
¢ a OWNER-BUILDER
DECLARATION
w u INFORMATION
A o a INFO A
w'; u r I hereby affirm that 1 am exempt from the Hu iressador s License MISC.- REF TO ORD
r ..0 Law for the ity or countywhihe. uiniso permitt to construct,
Professions PERMIT ISSUANCE ' 6.00 ' VALUATION S/FT.
Bewm0 imprve,d Any city or Or county any reqstructure,
permitto its issuance,also
- NO
Be improve, applicant Or sirh anyyelmCto File ai signed
itsiatement,ulm 'ELECCONT R. "UC.NO � ELEC. � r
O LL requires the applicant for such permit to file a signed statement that TOTAL
a w m he is licensed pursuant to the provisions of Ilie Contmclor's License RMIT TO-
i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
fi o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE '1
¢ I- m by any applicant for a perthe basis for the alleged exemption.Any violation o(Sedion 7031.5 IES - TYPE CONSTR.
n3'- mit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more Ili an five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with w5ges as' BACK FLOW PROTECT.DEVICE 2.00
their sole compens'arion,will do the work,and the structure is not - OC .GROUP S.UNI 5
Mnded or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
e:The Contractor's License Law docs not apply to an owner or - fj
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP' 4.00 SO.FT.FLOOR AREA TOTAL CREAGE
• himself or through his own employees,provided that such improve-
ments
mprove ments am not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1f I NC.4 OUTLETS 4.00
Or improvement is sold within one year of completion,ilia owner- BUILDING USE GAS-EA.SYSTEM-OVER 4(EA.) 4.00
builder will have Ilse burden of proving that he did nor build or am- RES IND CON PB Other
Prove for purpose of sole.) ' - INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS'-VINC 5 V.B. _ 5.00 �' ASSESSORS PARCEL NO. .
andan Professions Code:The Contractor's License Law does riot apply - -
• to owner of property who builds or improves thereon,'and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contrtetons)licensed pursuant to
the Contractor's License L,ov. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO: PARCEL NO.
❑ la exempt under Se BAP.C.for this WATER HEATER W/VENT 4,00
Ow"er- Date -1,J'", WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA1'ION DECLARATION' WATER TREATING EQUIP. 4.00
I hereby rhino that 1 Have-uceHilimtte ofcans"eat toself-insme,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.CJ.
Policy Nn. Company - -
O ❑ Certified copy is hereby tumbled FIRE SPgINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. . -
O Applicant - Y ❑ N❑ Y ❑ N❑
~'rn - - ' ' PERMIT ISSUANCE 6.00
LU - CIiRTI1lCC0 OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W �� COMPIiNSATION INSURANCE - PLG.CONTR. LIC.,NO.;. - PLG. ' '
CL Z (This .action need-not be completed if the permit is Car one _ TOTAL Y.❑ N❑ Y❑ .NO
hundred doilars(SIDO)or less.) +
U O ' I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE'SUMMARY
ILL I. mil is issued, I shall not employ any person in any manner so as to
UW - become subject to the Workers'Compensation Laws of Culit'omia. ,
Dutc A ireant BUILDING
} to NOTICE 'TO APPLICANT: If,after making(bisCertificate of lex- ALTER OR ADD TO MECH. 4.00
I- ? emption,you should become subject to the Workers'Compensation APPLIANCE P 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 10=CF.M.) 3.00 FEE
'CONSTRII(7TION LENDING AGENCY AIR HANDLING UNIT(OVER IO,ODDCEM.) 5.00 SEISMIC FEE
I hereby affirm that.there is a construction lending agency for EXHAUST HOOD (WITH DUCT_) 2.00
lire performance of the work lot which this permit is issued(Sec. MICROFILM.
3097,Civ.C.L HEATING UNIT TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT 100,000 B.T.U.)7.50 t �
Lender's Address ELECTRIC
I certify ilia[I have read this application and slate ilial the above VENTILATION FAN (SINGLE) 3.00
I � nfnrmation is correct. I agree to comply with all city and county PLUMBING
� 'ordinances and scam lawsrelating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.). 4.00
hereby authorise'represent utives of,this''eity to enter upon the 1-'
abovo-mentioned property or inspection purposes.fBOI LER-COMP(Con,100,000 BTU)SEE FEE SCH. MECHANICAL . +
I.(We) agree to save, indemnify and keep harmless the City of MISC. REFER TO ORD. '
Cupertino against liabilities,judgments, Costs aad expenses which PERMIT ISSUANCE' 3.00 CONST.TAX
in in any way Sccme against said City in consequence of the
I berg of lhi cr it. MECH.CONT. LIC.NO., - MECH.
L�,xC...1p9/'� y .'. TOTAL TOTAL
Signature of Applict/Conlrac I _
OFFICE COPY - -