5696 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON - PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT �^��
AomvEsS
(O BUILDING -ELECTRICAL-PLUMBING -MECHANICAL b
OW EP's PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
ONE i
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
PIP 14 I NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
is PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
sec.No. SIGNS TRANS. 3.00
ARC"OR
ENO, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00 //� ��
APPLICANT
AMOTORS SEE FEE SCH: �-V - /
ji�0S L f A y SERVICE CHANGE 10.00
woo LICENSED CON'1RACTORS DECLARATION
¢ I, 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
N <m (commencing with Section 7000)of Division J of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Cut.and.my license Is in full force a 'L If ❑ ❑ ❑ ❑
Z, Ll Ca Un C es Con Nwnbe
9 r DateWliContractor _
•� q. .1::. BUILDING PERMIT
OWNF,R-RUILDI:R DECLARATION _ INFORMATION
O A-O. MISC.--
I REFER TO ORD
w 3 w m I hereby al flan'ing rc or exempt boo lis Contractor'sLicenseVALUATION $/FT.
F .. O a Law for the following ma3on.(Sec.7031.5.BusinessmW Professions PERMIT ISSUANCE 6 00 �d 29
Code:Any City Or county which requires a Permit to coman¢L alter, ' /
QQ 0 improve,deomlish,Or repair UI�Istrncturc,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
ea -O IS requires the applicant for Such pennil o file a signet)statement that Ton 11. OTAL PERMIT TO
whe is licensed Pursuant to the Provisions'of tiro Contractors License '
H z i
Law(Chapter 9(cummcncingwith Section 7000)of Division 3 ofte
- < Business and Professions Code)or that hu is exempt therefrom unA QTY. PLUMBING PERMIT FEE
� IS . the bus i5 for the alleged sxem,tion.Any violation of S<clion 7031.$ _ STORIES TYPE CONSTR.
a ;� by any appli...I for a Perron subjects the applicant Uncivil penalty ALTER-DRAIN -WATER (EA.) 4.OD
of not more than five hundred dnllars($500).): iI a IZUo
❑ I,as owner of Rre Property or my st.... Yee,with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES,UNITS
Ihcir zoic<ohn,encition,will do Ihu work,and Rc iln¢Dva is not
intended or offered lit,sale(Sec 7044, Business and fruit c..ion, DRAINS-FLOOR,ROOF,AREA,CONIC. 4.00
Code'flre Contractor's License Law does not apply to an owner of
Property who huilds or iiiiprovcs thereon,and who docs such work FIXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,Provided that such ilnprove-
Troutsarenotintendedorofferedforsule.11,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvericnt Is sold within one year(it completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING WG USE
builds,will have the burden Of proving that ha did not build of inn RES tND CON PB Other
w
Prove for purpose of sale). INDUSTRIAL WASTE INTER. 20.00
❑ I,as ons,of tits property,ion exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to com1trum the Project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Codehe Contractor's License Law does not apply I
1.an owner of properly who huilds or improves thereon.:end who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlructons)licensed pontine to
Ili,Contrunnr'%License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iamcxemplunder .Sec. ,H.&1'.C.lin this WATER HEATER W/VENT 4.00
reason
Dw"Cr- Daie WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSA PION DIiCLARA'I[ON WATER TREATING EQUIP. 4.00
I hereby affirm Ihat 1 have a«rti0catc of consent to selNOune, ZONING ENG.SITE NO.
in a certificate of Workers'Compensation Insurance,or a certified
copy ahcreOfYSec.3800 1 ab.C.I.
Policy N'o.dYjja$ur' pany St"i9anf�
O ❑ Cenilied copy is hereby furnished. FIRE SPRINK ENERGY T-24
s Z 2 13..CerlifieA copy is filed with Ih• cilY inspection division.
O Applicant MISC.- REFER TO ORD. y Ell_ N❑ Y ❑ NC]
f ~ w ;t, PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.U.C.
� - CI RI'II4CCONI IN SATI N INN PROM E tKERS'
-LU � '.T-s.' S - CO}IPf:NSAI'ION'INSURANCE PLG.CONTE. ! LIC.NO. PLG. Y N V N
1"fins section need net he completed if the Pc nm it is for one TOTAL ❑ ❑ ❑ ❑
Z)AZ hundred dollars IS 100)or less.)
U O ' 1 certify that in the'performanee of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
`O_ H mit is issued,I shall not employ any person in any nhanner so as to -
U' become subject to the Workers'Compensation Laws of California.
U a Dale Applicata ALTER OR ADD TO MECH. 4.00 BUILDING
SU
} Of N01'ICIi '10 APPLICAN 1': If,after making this Certificate of[ix-
F 2 emplion,you should become subject 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 10fMC.F.M.) 3.00
CONSTRUGI']ON LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE ( t],
I hereby xft'inn 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.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Num° HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's AAAress ELECTRIC
1 certify that I have read this application and state Owl the above VENTILATION FAN (SINGLE) 3.00
. infonnation is correct. I agree to comply with all city and County PLUMBING
ordinances and state laws relating to buildings canietion, and BOILER-OOMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby autmriec representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpuras.
(We) agree to ...c, indemnify and keep Imnnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judglncnls, costs and expenses which CONST.TAX
may in any way accrue against .said City in consort acnec of the PERMIT ISSUANCE 3.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL (�1/
�..ti a�.IJ -/�-6'S' TOTAL (v^
Sigmtu®nf Applicunt/Cont...(or Dolc. '4 -
-INSP.• CTOR COPY \was aJ