7163 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
aoBUILDING NG
nRESS
0; V . 1. T__ /L_� //,,.-/E BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7163
OWNER'S /'� PLAN CHECK VALIDATION
NAME
�J� OTY. ELECTRIC PERMIT FEE
yY/ACTORS HONE
CONTRACTOR
MERAcrDns UTLEIL-SWITCHES-RECEP 5.00/1.00
T p
• G c.ND, � 6 LIGHTING FIXTURES 5.00/1.00
coNTRac OR's u
41-SIf PPLIANCES-RESIDENTIAL 4.00
AOOREss
SPHONE 67/`9 PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS g.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
(Iy hG GQ61?5!4 Imo. SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG. / SPECIALCIRCUIT 00 PERMIT VALIDATION
S7/�(JT zm / EMP.METER OR POLE INS. 1 .00
ADDRESS r'$ M TORS SEE FEE SCH.
ADDRESS U
'ar 0 II SERVICE CHANGE 10.00 ^//
o o LICENSED CONTRACTORS DECLARATION
G v u 1 hereby uffinn than I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N I'ndesions
v, Codc,and m licanu is in full force affect. ❑ ❑ ❑
0 o - License C 4 Lia Number
om r w Uatel( Contractor
¢ Y sBUILDING PERMIT
Iz Ix w¢ OWNER-BUILDER DECLARATION INFORMATION
MISC.- REFER TO ORD
w 3 U. m I hereby affirm that I sm exempt from the Contractor's License s VALUATION $/FT.
1-u O a Law for the following reason.(Sec.70J t,5.Rosiness and Professions PERMIT ISSUANCE 6.00
h� Code:Any CltYOr Cellnty which requires a permit to emisimmilter, ELEC.CONTR. LIC.NO. r
AP
a, ¢ o improve,demolish,or repair any structure.prior to its issuance,also Q / ELEC.
D IS requires the applicant for such permit to IIIe a signed statement that vollwechic 115Q TOTAL / 1 PERMIT TO
A e m he Is licensed pursuant to the provisions of the Contractor's License II�r
H z i Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 ¢o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IT H m the basis for rhe alleged exemption.Any violan ion Of Sect ion 703 1.5 STORIES TYPE CONSTR.
a = _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(550().):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
.I Their sole compensation,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:The Contractor's License Law does riot apply to an owner of
Property who builds or improves Omrcon,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 In'prove-
1�' meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement Is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 1.00 BUILDING uSE
builder will have the burden of proving that he did n - . - .
riot build or im- RES IND N PB Omer
prove for purpose of sale). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively'contracting with ElEl ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he 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 with a ecatusum')licensed pursuant to
the Contract.,',Lice...,Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for Ibis WATER HEATER W/VENT 4.00
caws
Owner lyase WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO..
WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have o certificate of consent I.self-in..BY, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,.,m certified
cosy thereof NS 3800,Lab.C.). f'7A ` !_mO
Policy NozgWompany /Zig W
Q C Certified copy ishereby faro ished. FIRE SPRINK ENERGY T-24
z Z 'II(CertifieAopy is tiled wl lh• city inspects, mvls n.
O Applicant-l!Llf/P--e�- �CIj C�/j4� MISC.- REFER TO ORD. Y❑ No , Y ❑ N❑
W CERTIFICAT T:OF EXF-MPI'ION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LL > ( COMP17NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O Illi is section need not be completed if the permit is for ,Be TOTAL Y,❑ N❑ Y❑ N❑
Z hundred delta,,IS 100)or less)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Ow hecomeSubject tothe Worker Compensation Laws of California. BUILDING
Is. Ura¢ ,lpplicant ALTER OR ADD TO MECH. 4.00
} m NOTICE '10 APPLICAN"1: If,after making this Certificate of E.-
F" Z cniption,you should become Subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)"C.F.K0 3.00
CONSTRUCTION LENDING AGENCY , AIR HANDLING UNIT(OVER I0)000C.F.M.) 5.00 SEISMIC FEE
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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
'' 1 certify that I have read this application and stain Thar the above VENTILATION FAN (SINGLE) 3.00
.� information is correct, I agree to comply with all city and cnt
ouy ordinancesg01LER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon Ibe g01 LER-COMP (Over 100A00 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a purist liabilities,judgments, costs and ,Spens..which PERMIT ISSUANCE 3.00 CONST.TAX
may in anyway accrue against Said City in cone,Loco. IT the
granting Of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL
X t TOTAL
Sign u e A:pph ant on[rac[or �Uat
I INSPECTOR COPY,