4468 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION PE)IT.NUMB ER _
BUILDING - APPLICATION &PERMIT 4468
ADDflE557�/9 T 0 e
1` BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
\' OWNER'S - PLAN CHECK VALIDATION
7 NAME ,,,/�'} TV. ELECTRIC PERMIT FEE
vHDNE�� VJ
CONTRACTORS -
`/ NnME OUTLETS-SWITCHES-RECEP 5.00/1.00
7W M 15hijOIC.N J1 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
ADDRESS _APPLIANCES RESIDENTIAL 4.00
NONE �Q� PANELS 5.00 DATE OF APPLICATION
ARCHITE T SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
no.A ess ENO' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS
MOTORS SEE FEE SCH.
�
SERVICE CHANGE 10.00 A'� p S
o
C2
/
r o o LICENSIiD CONTRACTORS DECLARATION O
a U I hereby affirm that I am licensed under provisions of Chapter 9 ANCE DATE
y< w (commencing with Section 7000)of Division 3 of the Business and L C. CT. PLG. MECH.
w'^ Pro fesno 'Code d my license is in full for �d.yffW.A� , ❑ ❑
o i ut o License Class Lic.Number ��77 pf ,
F ,n r J Date
Can tractor-
¢ >! s BUILDING PERMIT
E a w u OWNER-BUILDER DECLARATION INFORMATION
w3 A n I hereby affirm that I am exempt from the Con tractor's,License MISC.- REFER TO ORD yr,LDATION S/FT.
La u o J Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 6.00
rt aVs Code:Any city orcounty which requires a permit toconstracr,alter, ELEC.CONTR. LIC.NO.
p improve,demolish,or repair any structure,prior to its issuance,also ELEC.
D G rest Rimy the applicant for such permit to file a signed stat omen(Ilett TOTAL PERMIT TO
w$LL lie is licensed pursuant to the provisions at the Contractor's License
Fi> Law(Chapter 9(commencing with Section 7000)of Division 3oflhe RtQ00'a ZRr
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ I=- o the basis for the alleged exemption.Any violation of Section 7031.5 S ��D�RIIESSy TYPE CONSTR.
5_: by by any applicant for a permit subjects the applicant Loa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
�/Yq//LCs
of not more than five hundred dollars(S5001.):
❑ 1,as owner of the property,or my employees with 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,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 4.00 so.FT FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided that such improve.
menlsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 auaowG uSE
builder will have the burden of proving that he did not build or im RES IND CON PB Oma,
.
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 2000
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 . TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.forthls WATER HEATER W/VENT 4.00 .
reason
Dute Owner WATER SYSTEM - 4,00 ACC.DATE ACC.FILE N0,
WORK IIRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
hereby affirm that I have a certificate ofcnnsent to self-imure, - - ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy themof(Sec.3800,Lab.CJ.
Policy No: Company
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
ZZ ❑ Certified copy is filed with the city inspection division. REFER TO ORD.
O Applicant MISC- Y❑ IN Y ❑ IN
2y CERTIFICATE 017 EXEMPTIONFROM WORKERS` PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.D.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y[3 N❑ Y❑ NE]
CL Z (This section need not be completed if the permit N far one TOTAL
hundred dollars(S 100)or less.) '
U O I certify that in the perfomlence of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,1 shall not employ any person in any mannerso as to
U hoc b' the Wmkers'C pensation L' of lilorniu. / fa
U 0- Da Applicant` � ALTER OR ADD TO MECH. 4.00 BUILDING T r
} N N CF:TO LICANT: If Iter making R Certificate of Ex-
� ? c 1plim"you should become sh bjell 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 shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.NL) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING 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(Sec. MICROFILM
3097,Civ C.). H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
Icertify that l have read this application and,rate that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
-COMP(3 H.P.or 100,000 B.T.U.) 4.00
ordinances and state laws relating to building construction, and BOILER
hereby authorize representatives of this city to enter upon the BOILER-COMP 10ver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-nnenlioned property for inspectionpurposes
(We) agree to save, indemnify and keep hurmless the City of MISC.- REFER 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 3.00
gran[i0 Of lhi permit. MECH.CONT. LIC.NO. MECH.
41 -,�c� TOTAL TOTAL
'Si lure of Applicant/Co ractor Dale G
OFFICE COPY