5847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
'\ BUILDING - APPLICATION & PERMIT
y a nREss / BUILDING — ELECTRICAL—PLUMBING—MECHANICAL V T
7004 s C(QPSCP,V�" ACJ
Ow ER'S PLAN CHECK VALIDATION
" E / OTY. ELECTRIC PERMIT _ FEE
L y/,ltle&!4 L� 44C �U�q.[WPRONE
coNTRacrons p UTLETS-SWITCHES-RECEP 5.00/1.00 .
ME�A4 R 6laR6r/r/F N�G 5�. p r%P ILIGHTING FIXTURES 5.00/1.00
uc. �
ADDTRacaon's PPLIANCES-RESIDENTIAL 4.00
OUREss /r —
PIION —��
\ ZE ES GE 2✓T� PANELS 5-006 DATE APPLICATION
-
ARCHITECT 600 PLAN CHECKK FEE P.C.NO.
OR .
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDRESS ENG.
- SPECIAL CIRCUIT 5.001 `� PERMIT VALIDATION
ZIP TEMP.JMETER OR POLE INS. - ,15.00' ♦�
APPLICANTS .�.�
ADDHEs MOTORS SEE FEE SC /
LO 7��"�' SERVICE-CHANGE 10.00
o o LICENSED CONTRACIORS DECLARATION
v U I hereby affirm that I an licensed under provisions of Chapter 9 ISSUANCE DATE
y<N (commencing with Section 7000)of Division 3 of the Business and P}}}..G. ���iiiECH.
H w I'r(1fine ClS G 1�a Amy license is in full f ire•' f(xe s� ❑ �'❑ '.E Z};--I
y u u
I. O Z u, liccnsc Clas Lie.NumbA
Dal���— Qy 3 Can doctor
a x f s" _ BUILDING PERMIT
IS 2 w a OW'NIiR-BUILDIiR DECLARATION - INFORMATION
oAe' MISC.— REFER TO ORD
w g m I hereby affirm the 1 ann exempt from the Contactor',Liccnsc VALUATION
SIFT.
.. o a Los to,the following reason.(Sec.7031.5.Buslnessand Professions PERMIT ISSUANCE 6.00
rN Code:Anycityorcoumy which reyuiresa permit tocRNSN0CLalter, - Qo�
R ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.NO. ELEC. r U Vyr
0 Ic requires the applicant for Stich permit 10 file a ie,ned statement that TOTAL � _ERMIT TO �
u w mhe is licensed Pouanl to the provisions of the Contractor's License
z i e Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ Fm the baelsfor the alleged exemption.Anyviolation ofSection703L5 STORIES TYPE CO TR
e, _ by any applicant fora permit subjects the applicant o a civil penalty ALTER-DRAIN St VENT-WATER (EA.) 4.00 S N H2
W not more ton five hundred dollars(5500).):
.. ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the st ruclure is not OCC.GROUP R .UNITS_.S
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code'.The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4,0RD Sp//. s.Fy07 AREA TOTALACREaGE
himself or through his own employees,provided that such improve- , //
mems are not intended or offered for sale.IL however,the building GAS-EA-SYSTEM-I INC.4 OUTLETS 4100
or improvement is sold within one year of completion,to owner- GAS-EA.SYSTEM-OVER 4(EA.) 1-00 BUILDING USE
buik er will have the burden of proving that lm did not build or int- RES IND CON PB Other
prove for purpose of sale.). 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- 1 INC 5 V.B. 5.00 ASSESSORRSPARC51-NO.
and Professions Code:"the Contractor's License Law does not apply 3a e — /'/O — "a�
D an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA,) 1.00 l„ _
Its
mnlocts fiu such projects with a contractors)licensed pursuant to
the Crmracmr',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under$ca ,B.&I'.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMPFNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby ufOrm that I hove a certficote of consent to self-insure,
or a certificate of Workcri Cam .pi Snflam Ins.nmoo,.,:I certificc ZONING ENG.SITE NO.
Pcopy then�-•Pf1�IS'�$�RqQO(a"��.ab.CJ. t`R,/ s �^1
olicy NnM1l�Ge))Rpany 4J
OCertified copy is hereby furnished. FIRE SPRINK ENERGY T.24
Z0�� I�ILCerlificA copy f�+p�EwiO(� �d }�cdion division. MISC.- REFERTOORD. Y ❑ N❑ Y N❑
i N CERI'IFICATI!01'EXFMI'rION FRO_NI WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE ALUA.
W > CONiVENSATIONINSURANCE PLG.CONTR. * LIC.NO. PLG.
O (This section need mol be completed if the permit is for one ° TOTAL V❑ N❑ Y❑ N❑
Z hundred dollar IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner So as to
become subject to the Workers m
Copensation Laws of Colifinnia. y p
O w Date Ap l v - BUILDING �d0
CL 1"c°' ALTER OR ADD TO MECH- 4.00
} N NOTICE 'r0 APPLICANT: If,after making On,Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4-00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE.
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.NL) 3.00 ..
CONS'I'RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,000GEM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST H OD (WITH DUCT) 2.00 _
the performance of the.work for which this permit is issued(Sec. MICROFILM
- 3097,CIv.0.), HEATING UN (T0100'000 B.T-U.) 4.00 //
Lender's Nome
Lender's AddNames HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC (0
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 (n
information is correct. I agree to comply with all city and county PLUMBING �N
1 ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 - 1
above-mentioned properly for inspection purposes.
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over,100,000 BTU)SEE FEE$GH. MECHANICAL �« i
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs led expenses which - CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gramlip oft is permit. ECH.CONT. LIC.NO. TOTAL / n �� /A to
/Y1 �ti /—�— TOTAL
Signature of Applica Contractor Dale
INSPECTOR COPY