7269 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
y. BUILDING �. 7Z.69
/ ADDRESS
/ n1 lU B ILDING -
ELECTRICAL-PLUMBING-MECHANICAL
i
OWNER // PLAN CHECK VALIDATION
"AME U OTY. ELECTRIC PERMIT FEE 92 7� _
• �L LI O4 0 aN/IgHONE
NAME CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00 �j
LIC.ND. LIGHTING FIXTURES 5.00/1.00
CONTRAS
ADDH Pas PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
NGINEER
_ LIC.NO, SIGNS TRANS. 3.00
nooaess END SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 /Y
o o LICENSED CONTRACTORS DECLARATION
a vI hereby affirm Ihut I am licensed under Provisions of Chapter 9 ISSUANCE DATE'•- -
y a w (commencing with Section 7000)of Division 3 of the Business and BLD ELECT PLC. MECH.
F m z 1'ndessions Code,:rod my license Is in full force and effect. ❑ ❑
Z a o - License Class Lic.Number
o m D Uatc - Contractor '
¢ m fBUILDING PERMIT
¢ ¢ w IL
OWNER-BUDER DECLARATION
w ;A r- I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
o a law for the following reason.(Sec 703 L5,Business and Professions PERMIT ISSUANCE 6 00 / V�`LUATION 5/FT.
Code:Any cilyor county which requires a permit to construct,alter,
W R¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NQ ELEC, / 1
O c, requires the applicant for such permit to file a signed statement that TOTAL / PER TO
wm he is licensed pursuant to the provisions of the Contractor's License .(A�0✓
kwFyi
Lipa(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
Q
i o,, Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation o'Sectic n 7031.5 STORIES TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than live hundred dollars(5500).): '
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
>� their rocompensation,le copention,will do the work,and the Structure is not
� intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe Contractor's License Law does not apply to an owner of
t property who builds or Improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,Provided that such improve
mans are net intended proffered fur sale.If,however,the building GAS-EA.SYSTEM-1'INC.4 OUTLETS 4.00 ys1„r•'+`C
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 bunion 4proving that he did out build or im RES IND CON PB Omar
for pm"'ove of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner tit the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors IF, construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
add I'm Rsslons Code:'I'lie Contractors 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]or such projects with a contractor(%)licensed Pursuant to
the Contract,b Liccnsc Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am c ' .I and m. ,BAP.C.for this WATER HEATER W/VENT 4.00uit
1
reason
caner• F IF
Dat WATER SYSTEM 4.00 AACC.DATE ACC.FILE NO.
I WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 i •n"
I hereby affirm that 1 have acertificate ofeonsent to self-insure. -ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Iab.C.).
Policy No Company .
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-74
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y❑ N❑ Y ❑ IN
� T CER'I'IIICA'I'G OF EXEMPTION FROM WORK ERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > C041:NSAT'ION INSURANCE PLG.CONTE. LIC.NO. PLG. v[:] N❑ v C] NE]
0.0. I'rhis saclion need nut be completed if the permit is for one TOTAL
hundred dollar,IS I 00 or lass.) .�
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I Shall not employ any person in any manner so as to
U beamm subject to the Workers'Conhpensation Laws of California.
0UJ(L Uum Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE'1'O APP[,ICAN'I': If,after making this Certificate of Ex-
F Z enhption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
V Inch Provisions or this permlt Out be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.). 3.00
CONSTRUCT ION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE S�
I hereby affirm 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,CR.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT 100,000 B.T.U.)7.50 /J
Lenders Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. information is correct. I agree to comply with all city and county PLUMBING r ,�
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 10I BTU)SEE FEE SCH. MECHANICAL,-
above mentioned property for inspection purposes.
(We) agna0to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino uI liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in A y accrue against said City in c asequence of the
granting rmi MECH.CONT. - LIC.NO, MECH. n^
TOTAL TOTAL �f zry
U !/J v
9lgnamre of Applicant/ ontractor
Date
INSPECTOR COPY, ,ry