5448 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY,
BU LDI NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
BUILDING I APPLICATION& PERMIT
ADDRESS //]]
BUILDING - ELECTRICAL-PLUMBING _MECHANICAL 5448
OWNER' // PLAN CHECK VALIDATION
"AME ,I7`C✓ R IF' 'J �J TY. ELECTRIC PERMIT FEE
r Q ' UNE S J- /(
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
N
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. - SPECIAL CIRCUIT - '5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. - 15-00 p
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION'
a u v I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
m a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y z Professions Codc,and my license is in full force and effect. ❑ ❑ ❑
z o m - License Class Lic.Number -
Q z r w Date Contractor
c yUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
w0 a m . I herob firm that I am exec t loom the Contractor's License MISC.- REFER TO ORD
F 3 a 4 Law for the ireason.(Sec Following031.5.Businessand Professions PERMIT ISSUANCE 6.00 A N 5/FT.
Codi Any city or County which rcquires o permit to constrocL alley,
SE Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. - LIC.NO. ELEC. a
- O E requires the applicant for such permit to I IIC a signed stab nmol that TOTAL City RMIT TO
u w m he is licensed pursuant to the provisions of the Contractors License
a Law(Chapter 9(coinmencingwith Suction 7000)o1'Division 3 ofthe - sYC � J
4 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ F e, the basis for the alleged exemption.Any violation of Section 7031.5 - ST RI RIES �`•TT'YY,PE CONSTR.
n.,3 _ . by any applicant for a permit sunned,the applicant to civil penally - ALTER-DRAIN&.VENT-WATER (EA.).4.00 /SAV 40o<,E
- of not more than five hundred dollars(5500.) _
I,as owner of the property,or my employees with wages as- BACK FLOW PROTECT. DEVICE 2.00 occ.caD P RES.UNITS•
there sole r offered fo,will(S the work,:rad the nd Prof Is not - N L}
intended or offered for sale (Sea 7044, nosiness and it owneir of DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Codi I G Contractor's License Law does not apt o to n owner w of
properly. li builds or Improve:0 t and that
J . . i h work FIXTURES-PER RAPS 4.00 sea.Pr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.pr t IJcd th'f sur,h improve. -
mentserenollntenderl or offeredl sale.If,however,tire building GAS-EA.SYSTEM-1 INC-40UTLETS 4.00
or improvement H sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4(EA.)- 1.00 BUILDING USE
builder will have the burden of,raving that he did not build or Im- RES IND CON PR oma,
prove for purpose of sale.).. INDUSTRIAL WASTE INTER. 20.00 ❑ El C-1 ID F-1❑ I,as owner of the property,anclly
d exusivecontracting with
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'lie 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 contractons)licensed pursuant m
the Contractor's License Low. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
-711 1 arrc PI under Sea, ,B.&1'.C.f r this WATER HEATER W/VENT 4.00
reason
Owner' / �i rlfate WATER SYSTEM 4.00 ACC.DATE ACC FILE N0.
WORK ERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
hereby uffr o that 1 have a certificate of consent les sell-insure. - ZONING
or a certificate of Workers'Compensation Insurmrn:,or a certified - ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
O' ❑ Certified copy a hereby furnished. FIRE SPRINK ENERGY L24
z Z.,� ❑ Certified copy id filed with the city inspection division. REFER TO ORD.MISC.-
Q, Applicant Y❑ N❑ Y E) NE]
N CERTIFICATE 01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
DJ > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
CL 0 (This section need or he completed if the permit is (01 ane TOTAL v❑ N[] V❑ N❑
:D 2 hundred dollars(S 100)or less.)
-L) O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL} mit is issued,I shall not employ any person in any manner so as to
0 become subject to the Workers'Compensation laws of California. BUILDING �� a�
D. Date Applicant ALTER OR ADD TO MECH. 4.00
} Vat NOTICE TO APPLICANT: If,after making this Certificate of Fix-
F Z empton,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.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 3-0
I hereby affimothat there is a construction lending agency for EXHAUST HOOD(WITH DUCT) � 2.00
the performance of the work for which this permit is issued ISoc. MICROFILM'
3097,Civ.C.). HEATING UNIT(TO 100,000 B:T.U.) 4.00
Lender's Name HEATING UN IT IO VER100,000B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that l have ad this application a tion and state that tile Above VENTILATION FAN (SINGLE). 3.00
infortuation,is cu;recl. I agree to ply with all iIY and c my PLUMBING
r 1ordinancesand tat f ws relating tr buildi (, m vu t un end BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
heo,lby authorize representatives of this city toover open the BOILER-COMP (over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes: -
(We) agree IN Suva,-indemnify and kre, hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, culls and expenses which - CONST.TAX
stay in any way necme Mount said City in consequence of the PERMIT ISSUANCE 3.00
ng thin t mr. MECH.CONT. LIC.NO. MECH.
rorAL TOTAL
Signa arc of Applicant/Contractor - Dalc
OFFICE COPY