6984 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON APPLICATION & PERMIT PERMIT NUMBER
ADDRESS 6984
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OW 5 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE d�� (J /
PHONE Z /Vl-'u 7•-
- NAMER cT Rs UTLETS-SWITCHES-RECEP 5.00/1.00 .3
LIGHTING FIXTURES 5.00/1.00 f r
COR
rs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
d-�j - j�fj)orvE -� PANELS 5.00 BATE OF APPLICATION
"Z(T)
TECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
TIC.No. SIGNS TRANS. 3.00
ADDRESS Ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
2
zIP EMP.METER OR POLE INS. 15.00
AADDRESSrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 �-
w
Foo LICENSED CONTRACTORS DIiCLARATION
Q U I hereby aHire, Ihxt I ant licensed under Provisions of Chapter 9 ISSUANCE DATE
Nan (commencing with
IS 7000)of Division 3 of the Business arid BLDG. ELECT. PLG. MECH.
F y z 1'rtfcse Cla s , d y ' LySy i jlyfull fon�[J.yffEcy a/r
' 0.- License Class mbar Y(1 O rte'3 -
O F [)ate ` Cunlrador
El I El 0
El
a Y E -�' " -' #�TrE BUILDING PERMIT
0 i- INFORMATION
DECLARATION INFORMATION
'w g LL F I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION SIFT.
FUa4 Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code Any City or county which requires a permit to ceast ru.L alteq lG
rt ¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. TT
wD B, requires lite applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to lite provisions of the Contractor's License
H z i La..(Chapter 9(Commencing with Section 7000 ol'Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
a o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam by any applicant lura permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five lound ed dollars(4500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their side crompensation,will do the work,and the st recture is net
intended ooffered for sale (Set. 7044, Business and 1'rnfessions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Conlracmr's License Law does not apply to an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,Provided that Such inl4rrawe-
mc"Is are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one 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 build or int-
Poise for purpose of safe.). RES IND CON PB Other
❑ I,a owner of the property,an exclusively comrading with INDUSTRIAL WASTE INTER. 20.00 1:1 ❑ ❑ ❑ ❑
lieenxd contractors to construct the Project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
r and Professions Code:1'he Contractor's License law dues out apply
to an Owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a atntractods)licensed pursuant to
the Coulm,tor'S Licante Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
( ❑ f ant exempt under See.-,B.&V.C.for Olin WATER HEATER W/VENT 4.00 ;
letooll
E
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE N0.
f WORK ERS'COMPENSA'I ION DECLARATION / WATER TREATING EQUIP. 4.00
t I hereby affirm that I have a certificate of emsent to self-insure. f ZONING
+ or u cert ileate ul'Workers'Contpenmtion Insurance,or a certified ENG.SITE NO.
Copy mereef(Sec.3800,L dt,(_).
`i Policy Na. Company
CI Cerliriedco is hereby furnished FIRE SPRINK ENERGY T-24
Z Z' jy(Cerlified s t ) is Iilcd wiut city i action division. MISC.- REFER TO ORD.
'O A91'iCrr t Ig u. 1 YE] No Y ❑ N[]
CC y\ CiRTu' .ATI,OI'ExES N'PROM WORKERS. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.c.
L � COMPENSATION INSURANCE PLG.CONTR. � LIC.NO. PLG. ./ Y� N� YE] N�
d O ('flus caution "ted net be contplded if lite Permit is for one TOTAL ]--
0 Z hundmd dollars(S 100)or Icss.)
U O. 1 certify that in the performance of the work for which this Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL HJ, mit is issued, I shall not employ any person in any anr s
neo as to
[o�w m
hetome subject to the Workers'Cumpensalion Laws of California.
.a Datt Applicant ALTER OR ADD TO MECH. 4.00 BUILDING d v
} W NOTICE TO APPLICANT: If,after making this Certificate of lia-
r Z_ adoption,you should become subject to the WorkersCompensation APPLIANCE 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=C.F.M.) 3.00 FEE x
CONSTRUCT ION LhNUING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC.FEE �a
I hereby affirm that file. is a construction)coding agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cv.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this applicalion and state that the above VENTILATION FAN (SINGLE) 3.00
information is Correct. 1 agree to comply with ell city and coolly PLUMBING
ordinances and state laws relating to building construction, and BOILER-COIvB(3 H.P.Or 100,000 B.T.U) 4.00
hereby dtillhomentioned
representatives ins ec this city to ento upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovee-menlinned property forinsP ofth i Purposes.
(We) agree to use, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against mid City in consequence of the
gran lingo'this PC....it. MECH.CONT. LIG NO. MECH.
' TorAL TOTAL
SigR5F,RFTRf Appic radar Uale
INSPECTOR COPY
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