4892 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT,NUMBER
BUILDING I APPLICATION & PERMIT 4892 8 Q 0
AooEEss �} �1 [,
��' 703 � f, _ /� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"/"1 QTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
U AM
LIC.NO, /- LIGHTING FIXTURES 5.00/1.00
CONTRACTOR S PPLIANCES-RESIDENTIAL 4.00
ADDRESS p`Cf/.
YftlPHONE f/ PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
'UC.NO. SIGNS TRANS. •3.00
ARCH.OR ENG. $PE SPECIAL CIRCUIT S.00 PERMIT VALIDATION
A DORESs
ZIP TEMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH.
DREEssS
ADDR /
SERVICE CHANGE 10.00 r
wo o LICENSED CONTRACTORS DECLARATION G /
Or u 1 hereby affirm that I are licensed under provisions of Chapter 9 - ISSUANC DATE
I Q w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Code,9nd y -cense is in full force and of L ./ o �i. . ❑ ❑ ❑
Z, o m — license Class �� Lic.Number /1Y_)�7 ��L7 _
o H O Date-___FF .Contructor_Z_ �/`" ""^C� A C/N 6 f+' NO V S C IX r STi F.
y f R >-' T c IL!h 4 AN BUILDING PERMIT
I. a w a OWNER-BUILDER DECLARATION
w 3 a.y 1 hereby affirm that I am exempt from the Contractor's License
MISC.- `8tEFER TO ORD INFO
LL D a Law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE L ATION .+v I SOFT.
� - Code.Any City or County which requires permit tocunstrucLulter, 6.00
2 R Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- D 2 requires the applicant for such permit to file a signed statement that TOTAL PERMIT Q',�
he is licensed pursuant to the provisions of the Contractor's License. �'"�,
Hsi
Law(Chapter 9(commencing with Section 0000)of Division 3 of the E�,QQh
aOBusiness and Professions Code)or that he is exempt therefrom mid DTV, PLUMBING PERMIT FEE
r o the basis for the alleged exemption.A n I violation of Sect ion 7031.5 STORIES TYPE CONSTR.
n3:� by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).1'. . M&z)e
❑ I,as owner of the property,or any omployuci with wages as BACK FLOW PROTECT. DEVICE 2.00 Oc�r.,WU� pFS.UNITS
their sole compensation,will do the work,and,the structure is not 4� �
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -J
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such Work FIXTURES-PER TRAP 4.00 SO.FL FLOOR AREA TOTAL ACREAGE
himself re through his own employees,pnwid ed thus such improve.
mems are net hroug intended o,Offered for nculployeel,sale.If,however.such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the ownir- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden cf proving that he did not build or int- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 11 El El 1:1 1:1I,as owner of the properly,am exclusively cunt racling with
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCE L NO.
and Professions Code:The 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 tor such projects with a contractoosl licensed pursuant In
are Contractor's License Law. SEWER-SANITARY-STORM EA.200ST/8.00 TRACT NO. PARCEL'NO.
❑ l am exempt.,,it,,Svc._.B.&P.C.for this WATER HEATER W/VENT 4.00
"Too
Date - Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKE.RS'COMPENS\TION DECLARA'T'ION WATER TREATING EQUIP. 4.00 ..
I hereby affirm that I tare a cetlifimte nl consent to sell-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified _
ropy thereof(Sec.3500,Lab.0
Policy No. Company
Q pp ppEcrlififdcopy -herehy to..eh'd. FIRE SPRINK ENERGY T-24
z Z b�Ce Rcd�yopy sis dedeitl, e cit�nspection division. MISC.- _ REFER TO ORD. _ r❑ "❑ v ❑ .N❑
O Applicant (•
CCrT CEFT1FICA'I ELF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FL000 ZONE A.L.U.C.
LU >_ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
1 O (This Wetton need not be completed if the permit is for one TOTAL .Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.) -
U O 1 eerhii,.thal to the performance of the work On which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so a to
U become su ject� Ig�tl))eN'orkers'Cor}pensalioq�wsbTCalirni1: BUILDING
a Date—/ /_/L'yApplicant /�� ��JJ ALTER OR ADD TO MECH. 4.00
} to NOTICE 'f0 A�PPLLICANT: 11,after making this Certificate of E:x-
� Z emption,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'lhis permit slhall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 . SEISMIC FEE eS�
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(Ser. MICROFILM
3097,Civ.C.) HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l have read this application and state than the above VENTILATION FAN (SINGLE) 3.00
r Informaton is correct. 1 agree to comply with all city and count)' BOILER-COMP(3 N.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction. and
hereby authorize representatrves of this city to enter upon the BOILER-COMP (Over 100,000 BTW SEE FEE SCH. MECHANICAL
/ above-nhentloned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the Cily of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and asperses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gram n•ol'ti Paid II ' MECH.CONT. LIC,NO, MECH. O
L'�� fJ - ��G/F� TOTAL TOTALS-�
Signature of Applicant/Contractors vim
• OFFICE COPY
1