6922 i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 692
aoDREss f -h
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
h [
OWNER'S PLAN CHECK VALIDATION
f� NAME QTY. ELECTRIC PERMIT FEE ((''
11 J PRONE Q�q2-
C N RACTOR3 UTLETS-SWITCHES-RECEP 5.00/1.00
- 40_7, NAME Y
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S �o PPLIANCES-RESIDENTIAL 4.00 S�
ADDRESS
/ cj G ( e Vtn d HONE [C4' 3/S PANELS 5.00 DATE of AvvucarloN
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
AARC
DDRESS ENG. - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
aomess
/ ��
ADDRESS r$ MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 ��O i
'00 LICENSED CONTRACTORS DECLARATION "�.
a u b I hereby uflirn that I am licensed under provisions of Chapter 9 _I \, ISSUANCE DATE
w Q y (conunencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w Z Professions Code ]my license is in full f,).$$and(ffgc). ❑ ❑ ❑
z 0 m - icense Class Lir.Number a�F•+(,/ K .� ❑
O i :ca Date /?„ - 7 _ f� Contractor
a Y BUILDING PERMIT
¢
IS (c u OWNER-BUILDER DBCLARA'I'ION INFORMATION
wO s 1 herebyaffirm that 1 am exem t from the Contractor's License MISC.- REFER TO ORD
3'u w P - VALUATION $/FT.
F a.'0 Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 s w�
� y 0 Code:Any city or county which requires a permit to ron Mme,,, te
emoissuance,
q ELEC.CONTR. - LIG NO. ELEC. lr �� o-�/-v
¢ Q O improve,demolish,or repair any structure prs I
prior to itssuance,also
D¢ reinces the applicant for such permit to file a signed statement that TOTAL // PERMIT TO
A ac m he is licensed pursuant 1p the provisions of the Contractor's License
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the �OQi��U v✓
- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
(c Oo STORIES TYPE CONSTR.
¢ the basis for the alleged exemption.Any violation of Sect ion 703L5
ate_ by any applicant For apennil subjects the applicant loacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not nmre than five hundred dollar,($500).).
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00
their sole aOnl ITensntion,will do the work,and the structure knot OCC.GROUP BEs.UNITS
intended or off n,d for sal,(Sec. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law docs not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 so.Pr.FLOOR AREA TDraL acREaGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.If.however,the furling GAS-EA.SYSTEM-11NC.42TLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.$V STEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.]. INDUSTRIAL WASTE INTER. 20.00
CI 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑'
licensed comr,ciors 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 will,a contraclorts)licensed pursuant t0
The Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. .BAP.C.for this WATER HEATER W/VENT 4.00
reason
OwncT Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.,
WORKS RS'COMI'ENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby atlir t that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certilicme of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.L R�
policy No. Company
b 0Certified I b I, niched. \,.
copy is y FIRE SPRINK ENERGY TZ4
Z 2 - ❑ C,rt l'"u p is Itle ith g city inspedion division.
O AllpliCarl � ! MISC- REFER TO ORD. Y ❑ N❑ v ❑ N❑
0: T CEIfI'IFICA'I'1i OF]XFM VI ION FROM WORK ERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.IC
LU > COId PFNSA'1'ION INSURANCE PLG.CONTE, LIC.NO. PLG.
CL ❑ 1 Phis section need not be completed if the permit is I'or one TOTAL Y❑ N❑ Y❑ N❑
D Z handfed dollars IS I GB)nr less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL E- mil is issued, I shall not employ any person in any manner so as to
0 U become subject to the Workers'Compensation Laws of California. 7 S'0
d Dale Applicant �sd
} rA NO'I10E'10 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 BUILDING
Z eruption,you should become subject to the W'orkeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with .FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=17.F.M.) 3.00
CONS'rRUCTIONLENDINGAGENCY AIR HANDLING UNIT(OVERIO,000C.F.M.) 5.00 SEISMIC FEE S'y�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perlormance of the work for which this permit is issued(Sec. MICROFILM
3092 Civ.C.]. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T-U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state find the above V ENTILATION FAN.(SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 4.00
hereby authoriea representatives of this city toenter upon the BOILER-COMP(Over 100,000 RTU,SEE FEE SCH. MECHANICAL
ahove-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again,at liabilities,judgments, costs and expenses which CONST.TAX
may in any way aicmc against said City in consequence of the PERMIT ISSUANCE 3,00
gmnl ag it Ibis pcnuil. MECH.CONT. LIC.NO. MECH.
_ _ TOTAL TOTAL
Sign tum of Applicant Contractor Date
INSPECTOR COPY