6901 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT r6901
r BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
' OWNER'S PLAN CHECK VALIDATION
_ NAME1 QTY. ELECTRIC PERMIT FEE
CPHONE
r I D D
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
LIc.rvD. 7 LIGHTING FIXTURES 5.00/1.00
c NTRAcU APPLIANCES-RESIDENTIAL _ 4.00
ADDRESS
/ PRONE q - O PANELS / 5.40 DATE OF APPLICATION
A mTECT SIGNS BAD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC No. SIGNS TRANS. 3.00
AR[DlR'E SS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S f ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
ohoI... LICFNSEDCONTRA(.TORS UECLARA'r1ON
Q_o p I hereby OR....that I um licensed under m.O..ons of Chapter 9 ISSUANCE DATE
N G h (connnencmg with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Code,W{BI my license is in full force and effect, d ❑ ❑ ❑ ❑
z O,w - License Class_IF 5 Li,
.Number
9 y r °w Date_/_2 7 Contrachm
r- - J
a re re J r BUILDING PERMIT
at 0 w a OWNIi R-fi UILDIiR DECLA RA' N INFORMATION
u I he¢by Alma that 1 am exempt from the Corel moors Licasu
MISC.- REFER TO ORD
Hu04 Law lot the the following rcason.(see 7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FL
Code:Any city or county which requires a permit f o construcL alter,SE aa �r
Q improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO.
ELEC.
an
- O w requires the applicant for such permm
it to file a signed matcenl that TOTAL PERMIT TO
w ms is licensed pursuant In the provisions of the Contractor's License V
'' rzQ Law(Chapter 9(commencing wi th Sect int 7000)of Division 3 of l he
.1 Business and professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Y re 10. the hasis for the alleged exemption.Any vwhuion of Section 7031.5 STORIES TYPE CONSTR.
dam _ by any applicant for a permit subjectsthc applicant toacivilpenatty gLTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S5O0)J: .w d
CI Las owner of the property,or my employee with wages as BACK FLOW PROTECT.DEVICE 2.00 Dec.GROUP BEs.UNITS
(heir sole cunipatsatinn,will Jo 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 not apply to an owner of
properly who builds or Improves thereon,and Who does Such work FIXTURES-PER TRAP 4.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided Out such improve-
memsarenotintendedorofferedforsale.If,however.the budding GAS-EA.SYSTEM-1 INC.40UTLETS 4.00
or improvement is sold within ane year of,completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the Burden of proving that he did not build or in,
prove for purpose ofsale.). RES IND CON PB Orhar
p ❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
• licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.8. 5.00 ASSESSOIDARCIRO.
and Plafcss'io t,Code: LIB,Contractor's License Law does not apply
to an owner rel property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractoos)licensed pursuant to "
the Contracmr's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam exempt mldur Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reawn
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0,
WORKP.RS'COMPENSATION DFCLARATION WATER TREATING EQUIP. 4.00 /)Z '�
I hereby atHnn that I have a certificate ofc.nsent to self-insure.
or a certificate of workers Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy Ihcmol(Scc.3A00,Lab C) / n
Policy N'o. Company ���• qCr ro,.17
O ❑ Cetlilied c y is hereby luntished. FIRE SPRINK ENERGY T-24
z Z Ccni is tiled It he city inspection division. MISC.- REFER TO ORD.
Q pplicam V❑ N❑ V ❑_ N❑)
( cr = CERTATI:01:E XESIPTION FROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE A.L.U.C. '
W > COMPEN$A'I'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q. o ('['his section need not be completed if the permit is for one TOTAL 0 Y❑ N❑ V❑ NE]
r ::) 2 hundred dollaR(SI00)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- if is issued.I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
f O w Data Applicant BUILDING
a ALTER OR ADD TO MECH. 4.00
} Do NO'rl CE 70 APPLIC\N'L: If,after making this Certificate of F.x-
2 eruption,Youshould become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must lorthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op00CF.NL) 3.00
CONST'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.F.M.) 5.00 SEISMIC FEE
I hereby alfirm that there is a construction tending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ CA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NamAdd
e HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree.to comply with all city and counry PLUMBING
ordinances and state laws relating to building construclion. and BOILER--.COMP(34H.P.or100,000B.T.U.) 4.00 /U
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree m save, indenmify and keep harmless file City of MISC.- REFER TO ORD. .L
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX \
may in an ay accrue against said City in consequence of the PERMIT ISSUANCE\ 3.00
gran l ing tis permit MECH.CONT. LIC.NO MECH.
/ o TOTAL TOTAL
Igo lar Appli amt/Contractor /Date /
INSPECTOR COPY I