2858 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13UI LOING PROJECT I DENT[FIC TI IN PERM N
BUILDING APPLICATION & PERMIT Q58
V�J V
Al
'C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Ow ER'B PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
el,4 Po z
coNT OR UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Q I 7 YJ� LIGHTING FIXTURES 5.00/1.00
CnDDRE 5DNTRACT RS PPLIANCES-RESIDENTIAL 4.00
-^
PANELS 5.00 onrE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
nGN'Ess ante, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. .00
APPLICArvT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 1 _ / Z /�
r
.2 LICENSED CONTRACTORS DECLARATION �/ ih9yf L
1 v w I hereby afrom Hall n licensed under provisions of Chapter 9 ISSUANCE DATE
N Q (Commencing it Ccti 70001 of DIvRion 3 of the 11qH,ire,,and ,p BL L T. IMVI MECH.
H i Professions s , nJ uue is in full f 'L�- ❑
0 Coo - License Class Con Nwnbc L.
o z r � Date Contractor � I IT
H N
a,w ¢ OWNER-BUILDER DECLARATION INFORMATION
0aU MISC.- REFERTOORD
N
S u m I hereby allirm that I am exempt from the Contractor's License 6 VALUATION $/FT.
LL o j Law for the f.IIRw ng rt'ason.(Sec.7031.5,Businessand Pmfcssiums PERMIT ISSUANCE 6.00 p
� - Code:Any city or county which rL•quiresa permino construct,alter,
e,a ac 0 improve,demolish,or repair any Structure,prior to it,issuance,also ELEC.OONTR. LIQ N0. ELEG. Ojj_
0 , requires the applicant for such permit to file a signed stalvinent that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
EIo
¢ H m the basis for tate alleged exemption.Any violation ot$ection 703 nalty STORIES TYPE CONSTR.
a 3 _ by any applicant fora permit dollars the applicant mucivil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars($5001...,
❑ Las than
ar we property, it By,and(lies with rewages os BACK FLOW PROTECT. DEVICE 2.00 Oct.GROUP RES.UNITS
their solo compensation,will(S tinx work,end Ilse 9inletare is not
intended or offered for sale (Sec. doe Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00
Code:The hContractor's buildsor License Law does not apply to an owner of
property who buildsorimproves thereon,and who does snch work FIXTURES-PER TRAP 4.00 5a.FT.aooR AREA TOTAL ACREAGE
. himself re through his own employees,provided that such improve-
ments
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
GI Improvement is sold within ane year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not huild or im-
Proveforpurposcofselc.). INDUSTRIAL WASTE INTER. 20.00 Res mo CON PB 0"'1,"
Prove
I,as owner of the property,am exclusively contracting will, ❑ ❑ ❑ ❑ ❑
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 docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contractsfor such pro�1'PpeI with a cornruaonsl licensed poramia to
the Contractors Ln4se Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT No. PARCEL No.
❑ I am ea under Sec. ,B.&P.C,for this WATER HEATER W/VENT 4.00
rcuso
Date 11'� Owner - WATER SYSTEM 4.00 ACC.OATE ACO.FILE NO.
M'ORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
ora certificate of W kers'Compensation I stlfance,or a certified ENG.SITE NO.
copy ther���{/y.�,Y1. /•!IL
Policy N�i.�'emPI V
Q ❑fcitified ofy Is In nr by Lonuhcd. FIRE SPRINK ENERGY T.24
Z 2 - REFER TO ORD
�'Cert iii d ,it MISC. .
O Apple", Y ❑ N❑ v [:] N❑
� y CHRT'IFICATEOPI\f:Ml'I'ION FR 011WIRM1F-RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU.C.
W > COMPENSAT'ION INSURANCE PLG.CONTE. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
::) 2 hundred dollars IS 100)or less.)
U O I certify that in the red'ormm bl ilio work Ibr which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
L.T. 1- mit is issued.I shall not in unY permn in any manner so os to q
U become subject to'lie
rs' .ompensation Laws of California. BUILDING pZa �
Cut Datc A ca ALTER OR ADD TO MECH. 4.00
} to NOTICE'I'O APP AN : If,after making this Certificate of t
F 2 emption,you shoo d become subject to the W'orkeri 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 10MOC.F.M.) 3.00
CONSTRUCT'ION IJ' gi AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE �U
I hereby affirm that there construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perfonnmme of the wo which this permit is issued(Sec. HEATING UNIT ITO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.l.
Lender's Name H EATING N G U N IT 10 VER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. Infonustlon is correct. 1 agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construction.and
hereby aithowe representatives of this city to enter upon the BOILER-COMP love,100,000 BTU)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 aBam, liabilities,judgments, .,Is mW expenses which CONST.TAX
may ri ny c tie against saW ty in consequence of the PERMITISSUANCE 3.00
graf IMECH.CONT. LIC.N0. MECH.
TOTAL TOTAL 31 ,0
Signatumo ApOhcal /Contractor Date
OFFICE COPY