C5704 (2) Y
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT
Ap RES$
1 _ BUILDING — ELECTRICAL—PLUMBING—MECHANICAL i � 5704
11J i
OwNER'S ALAN CHECK VALIDATION
NAME i TY. ELECTRIC PERMIT FEE
vmaNE 53-� 1
rvomERACTorrs OUTLETS-SWITCHES-RECEP 5.00/1.00
(�E.Ic.No. �{ LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
AOOREss 1 �•
( ,,.NE Lo bi LoPANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 . PLANCHECKFEE P.C.NO.
OR
ENGINEER 3.QD LIG NO. SIGNS TRANS. r f /
ARCHEOR ENG SPECIAL CIRCUIT_` - �I /�� -5!00 PERMIT VALIDATION
14 'IF EMP.METER OR'POCCINS!! /15.00 �✓ ,�< /o•�i/�
APPLICANTS - MOTORS SEE FEE SCH.
auoREss
tr SERVICE CHANGE 10.00 v/•(j
0 ¢z
Foo Llf.IiNSEU CONTRACTORS DEChARA'f10N 9
4 u v I hereby air nu O®t I am licensed under provisions of Chapter 9 ISSUANCE DATE
yz"' Oxuun en6n with Section 7000)of Division 3 of the Business and
a w K w BLDG. ELECT. PLG. MECH.
F w z Prol'essimu Code n license is in full forceaud c ec. 0 ❑ ❑ ❑
Z,i m o License Class . I.ic.Number
N H Date Contractor
m E BUILDING PERMIT
F O a U
OWNER-BUILDER DECLARATION INFORMATION
F
I hereb affirm that I run exempt from the Contractor's License MISC.— REFER TO ORD
LL < y p VALUATION $/FT.
F _o¢ Law for the,folluwing reason.ISec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 A\
m w Code:Any city orcounty which ruquiresa permit to construct,alter,
> 'm rove,demolish,or repair an Structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
¢
at 0 improve, pa Y P ELEC.�
Emu requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
La he is licensed pursuant to the provisions of the Contractor's License
z ¢ Law(Chapter 9(commencingw'ith Section 7000)of Division 3 ofthe _
P 4 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
EE l is basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollms($500).):
❑ I,.e;owner of the property,or myemployees with wages as BACK FLOW PROTECT. DEVICE 2,00 J OCC.GROUP 'RES.UNITS
- 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 not apply to an owner of
property 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 that such improve '
Imus are not intended oroffered fur sale.if,huweveq the building GAS-EA.SYSTEM-11 NC.4 OLTLETS 400
ur improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA.1 1.00 BUILDING USE
r builder will have the burden of proving that he did not build or im- - . -
RES IND CDN PB Omar
prove for Purpose cfsale.l. INDUSTRIAL WASTE INTER.- 20.00
I7 1,as owner of te hProperty,am esd... t,ly c.nHu0in,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 docs not apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts far such projects with a mnlractods)licensed Pursuant to `
it,,Comfactor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec.—,ILAP.0 for this WATER HEATER W/VENT / 4100
reason
Owner Date WATER SYSTEM `� 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to selfinsure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy there Cf Sec 3800,Lab.C.). __, -
PolicY No,[7 co 2 i(mtpany �N[7
Q ted copy ishnreby famished. 7 FIRE SPRINK ENERGY TQa
z z Certify�d copy is i7e OIf�t�he ity'inspection division. '
O Applicant YP w,,Z2Ap� V� MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
HT I�OblF PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
CER'I'1191CCOMOP SAIDO PINS FROM WORK ERS,
LU > I io COhi l,of be coo INSURA NCI: PLG.CONTR. LIC.NO. PLCCL 0 . Y❑ N❑ Y❑ N❑
Z) z his scatie.. need not he completed it the permit is for onu. TOTAL
hundredly that in the perfoor rmance
U O 1 certify that h l n performance of the work for which This per, OTY MECHANICAL PERMIT FEE FEE SUMMARY
0 H mil is issued,I ,shall not employ any Person in any manner or as to
U M1cmme subject to the Workers'Compensation Laws of California. tJ
EL Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE '1'0 APPLICANT: If;after making this Certificate of Ex-
F z eruption,you should heron,subject to the Workers'Compctaatlon APPLIANCE t 1 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. 1 AIR HANDLING UNIT(TO 30)000C.F:M:)�.3.00
CONS'PRIICfION L17N DING AGE. AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE t5(�
1 hereby uf1'imt that there is a construaiun lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sea MICROFILM
3097,Civ.C.1. HEATING UNIT(TO 100,000 B.T.U.) 4.00
I,endeh Name HEATING UN IT(OVER 100,000 B.T.U.17.50
Lender,Address ELECTRIC
I certity Hui l have read this application and state that I above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building contraction, and BOILER-OOW(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city ", enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
uhove-nientioned 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 said City in cons"uence of the PERMIT ISSUANCE 3.00
gmnlingoflhis Purmit. MECH.CONT, LIC.NO. MECH.
n TOTAL TOTAL
signaltk
pPbcam/Contracmr Date /
INSPECTOR COPY