C5704 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE-BALL POINT PEN ONLY
-BUILDING PROJECT IDENTIFICATION. PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS V I/
1_ 570 4
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL '
'l wNER'SHECK VALIDATION
. 'NAME a QTY. ELECTRIC PERMIT FEE
A,1V
PRONE 53- �,
coNTBacroRs _ UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
t'
Ii 11
c.No. ' LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS APPLIANCES-:RESIDENTIAL 4.00
1 _ II,^.
i PHONE LD WI PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINPER
LIC,NO. SIGNS TRANS. 3.00
nOCK.ss ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
14 ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT S0 SEE FEE SCH.
ADDRESS
I SERVICE CHANGE 10.00
0 0 0 LICENSED CON TRACTORS DECLARATION AL3 xv-
U I hereby affirm that I am licensed under provisions of Chapter 9 1 ISSUANCE DATE
y a y (commencing with Section 7000)of Division 3 of Ole Business and _ 2 ELECT. PLG. MECH.
e, w z Professions Cod am license is in full for-•'I d f c ❑ ❑
i'o e,m — Liccmc Class yfc Lic.Number
O 2 — O Dnlc Contractor "
a YMA B NG PERMIT
rc It w OWNER-BUILDER DECLARATION -
INFORMATION
'w; LL N I hereby affirm that I am exempt front the Contractor's License
MISC.-- REFER TO ORD
.. oa, Law for the following mason,(Sec.7031.5,Businessiod Professions PERMIT ISSUANCE 6-00 I of S/FT.
CnJc;Any city or county which requires permilMcrnMrucL aticq /� ��/b �`
QQ Q p 'Improve,demolish,Or repair any Structure,prior to Its issuance,also CLEC.CONTR. LIC.N0. ELEC. 51 x„J ♦ I ✓
E a u requires the applicant for such permit to file a signed statement that TOTAL' PERMIT TO
A w he is licensed pu rsuanl to the provisions of the Contractor's Licens,
Law. Chapter 9(commencing with Section 7000)o f Division 3 of the —
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.,
ca ;m by any applicant for a permit Subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of riot more than five hundred dollars(S500).L •��C
01,as owner of the property,or By employees with wages as ggCK FLOW PROTECT-DEVICE 2.00 OCC.GROUP RES.UNIT$ -
tl,elr 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'Tire Contractor's License Law does riot apply loan owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.0 50.FT.FLOOR AREA TOTAL ACREAGE
hinaullor through his own employees,provided that such improve- -
mm�tsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 4.00
or improvement is sold within one year oI'completion,the ownerGAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
RES will have the burden of proving that he Aid not build or ire- •RES IND CON PB . Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of(lie property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
.allProfessions Code:The 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 coulractorts)licensed pursuant to
tele Cont metrics License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,BAP.C.for this WATER HEATER W/VENT 4-00
reason
Owner Dare WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
, 1 WORK F-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. '4.00
I hereby affirm that I have a certilicateufconsvnt tosulpinsure. ZONING ENG.SITENO.
or a cerlilicale of Workers'Compensation Insurance,or a certified
copy lhcre__o��ff(Sec 3800,Lab.CA C..' I -
Policy Ise, a39{Impany T iD
O' I.'��.er[Tire copyLs
%`m-clay❑Imo coil. FIRE SPRINK. ENERGYT"24
z Z IS f.ern if A y " {Ihd t[ th ty-inspection division. -
FO' nPPlic:wt�PN�mlet4�—L.n 1'y/l1Lr�.../t� MISC.- REFER TO ORD'. v❑ N❑ v ❑ ; N❑
CC m CERTIFICA'r Ii OF EXEMPTION('ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
UJ COMPIiNSAT1ON INSURANCI: PLG.CONTR. LIC.No" PLG.
a 0 (this Section need riot be ecrlpleted If the permit is for .11C TOTAL Y❑ N❑ - Y [:] N❑
Z Imndned dollars(S 100)or less.) -
U O 1 certify that in the performance'of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I Shall not employ any person in any manner So as to
U become subject to the Workers'Compensation Laws of California.
U y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
>_ w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emulation,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 /l
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 5.00 SEISMIC FEE f�V
I hereby affirn that there is a construcliou lending agency for EXHAUST HOOD(WITH DUCT) 2-00
Ihe"c'u nuance of the work for which this Durant is issued(Sec. - MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
'Lenders Nance
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC'
I certify ([car l have read this application and state that lire above VENTILATION FAN (SINGLE) 3100
information is correct.I agree to comply will,all city and countyPLUMBING ,
ordinances and state laws relating m building construction, and
BOILER=COMP(3 H.P.or 100,000 B.T.U.) 4.OD
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 to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX -
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE - 3.00
grantingof lir is permit. MECH.CONT. - LIC.NO. MECH.
TOTAL ]::TOTAL Cyt
Si native of Applicant/Contractor Uate /I
" OFFICECOPY