The URL can be used to link to this page

5857APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ' BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER BUILDING :� aooREss; Q3SS BUILDING -ELECTRICAL- PLUMBING -MECHANICAL �� r Owry L'R'S PLAN CHECK VALIDATION NAME OTY. ELECTRIC PERMIT FEE PHONE CONTRACTORs UTLETS- SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 1,rdl.e .40 -' CONTRACTORS �1 ? DDPE5 A5 Y�/ PPLIANCES- RESIDENTIAL 4.00 PANELS 5.00 HOrvE DATE OF APPLICATION ARCHITECTSIGNS OR ENGINEER uc. No. g.06 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH OR ENG ADDRESS SPECIALCIRCUIT- 5.00 PERMIT VALIDATION frEMP. METER OR POLE INS. 15.00 21v APPLICANTS apOREss MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 YAl LICENSED CON'FRAC'ORS DECLARATION I hereby affirm that I am licensed under provisimis of Chains, 9 l.onmmncin, with Section 7000) of Division 3 of tiro Business and Professions Code, nd 1 'cost.' is in full forte e d `f `ft License Class Lis. Number ISSUANCE DATE BLDG. I ELECT. I ❑ ❑ PLG. MECH. ❑ ❑ Datc-IILa_e/�10 Contractor -�gfl,y-f„/�e�, BUILDING PERMIT INFORMATION OWNER-BUILDFR DECLARRATI.O•N, r I hereby affirm that I and uxunlpt from the Contractor's License Law for the following reason.(Sec. 7031.5, Businessand Professions Code Any city or county which lectures a permit to Construct. alter, unprlwe, demolish, Or repair any structure, prior to Its Issuance, also equines the applicant for such permit t0 file a signed store pent that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing w'illl 5eaion 7000).(Division 3 of the Rusiness and Professions Cods) or that he is exempt therefrom and MISC. - REFER TO ORD VALUATION '.. S/PT. PERMIT ISSUANCE 6.00 ' ELEC. NO LIC. . / 'E LEC. iOiAL PERMIT TO -/ L C. QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of5ectfon 7031.5 by any applicant for a permit subjects the applicant IDS civil penalty of not more than five hundred dollars(8500LL ALTER -DRAIN & VENT -WATER (EA.) 4.00 ❑ 1, as owner of the property, or my employees with wages as their sols compensation, will do Ole work, and the structure is not BACK F LOW PROTECT. DEVICE 2.00 occ. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for sale (See. 7044; Business and Professions Code: 'file Contractor's License Law does not apply no an owner of properly who builds or improves thereon, and who docs such work lifinself or nhrongll his Own employcfs, provided that such improve- mentsarenotintendedoroffered for sale if, however, the building FIXTURES - PER TRAP 4.00 SO, FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM -1 INC -4 OUTLETS 4.00 or improvement is sold within one year of completion, the owner- builder will have the burden of provins that he did not build or im prove for purpose of sale). ❑ I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 2000 . licensed contractors to construct the project (Sec. 7044, Business and Professions Code I'hc Contmaor's License Law does not apply to an owner of property who builds or improves thercon. and who LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. theCont lot such cense ts Lwithucnntmaur(s)IiccnscA pursuant In the Contractor's s Liccaproje Law. ❑ lam exempt under See. B:&P.=. for this ma on ! SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. 1 PARCEL NO. WATER HEATER W/VENT 4,00 Owner /' / Date '.•� WATER SYSTEM' -4.00 ACC. DATE ACC. FILE NO. _,,WATER TREATING EQUIP. 4.00 WORK ERS'COM PENSA'11 IpN DECLARATION I hereby affirm that I hav fvRtifmate of consent to self -insure.. or a certificate of Workers' G6 pensation Insurance, ora ccertified' furry Ihcreof (Sec. 3800: KIN C.). / eO.QrMY�FW �:� ZONING ENG. SITE NO. Policy No. Company Its � ❑ CfrtiGe� is hemby famished. fXly C4IIIBCd Opy Is Filed with the city inspection division. .A IIIIIICam .di np , FIRE SPRINK Y ❑ N ENERGY T-24 Y ❑ N❑ IMISC. - REFER TO ORD. - CE�R'TIFICATEwO(I:XFMP1 ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSA'I' ION INSURANCE t'I"his section need out be completed if the permit is Itrr one Y ❑ 14❑ t Y ❑- IN [-T LJ hundred dollars IS 100) or Is. 1 certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING Income subject to R the W'orkeli Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 4.00 NO'13CE 'f0 APPLICAN"I': If, al ler making this Certificate of Ex- APPLIANCE 4.00 PLAN CHECK nr7 emption• you should become subject to the Workers' Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this pe;Rdt deal be deemed revoked. FEE O AIR HANDLING UNIT (TO 10MC.F.M.) 3.00 AIR HANDLING UNIT (OVER 10MC.F.M.) 5.00 $� SEISMIC FEE ' CONS'TRUCfION LENDING AGENCY I hereby affirm that there is a consvnction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 lite performance of the work ter which this permit is issued (Sec. 3097, Civ.C-), �► MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATINGUNIT(OVER IOO,000 B.T.U.17.50 ?, 2. ELECTRIC 5luk .y_ r/JaAJ«.n Lender's Name R Lender , Address VENTILATION FAN (SINGLE) 3.00 I Certify that 1 have read [his application and nate that the above information is correct. I agree to comply with all city and county ordinances and state laws Mont; to building construction, and PLUMBING gQILER-COMP(3 H.P. Dr 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL "t.2 hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City o1' Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the CONST. TAX - PERMIT ISSUANCE 3.00 .� grantin of this rmiL MECH. CONT LIC. NO. MECH. 9 /a67zz /�H �N Ica TOTAL 4G- � TOTAL civ $i tare o App ant/Contractor Uat INSPECTOR COPY