6710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT,PEN ONLY
BU I LDING PROJECT I DE NTI FICATIONPERMITNUMBER ,.
DO LOiNc APPLICATION & PERMIT
ADDRES+S�
WOO BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 6710
OWNER'S - PLAN CHECK VALIDATION
NAME I- QTY, ELECTRIC PERMIT FEE
i� - / PHONE r
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
'uc.No. LIGHTING FIXTURES 5.00/1.00
ADDRESS Rs m"'O pvL CA �/n� PPLIANCES-RESIDENTIAL 4.00
ADDRESS �T YY/
( PHONE 3,D)i PANELS 5.00 DATE OF APPLICATION
ARCHITECT .$IGN$ 6.00 PLAN CHECK FEE P.C.NO:
OR
ENGINEER .
LIC.No. SIGNS TRANS. 3.00
ARCH.
RC Ess ENG: .00- - ` SPECIAL CIRCUIT. 5PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS I �,
SERVICE CHANGE 10.00
wo o -• LICENSED CONTRACTORS DECLARATION
a o b I hereby affirm that 1 am licensed under provisions of Chaplcr 9 ��ISSUANCE DATE
v,a w (annmencing with Section 7000)of Division 3 of the Business and 110
LECT. PLG. MECH.
H o z Professions Code,nd iry license is in full force and effect. _ d ''1 �� a ❑
z O H - License Clare X Lia Number
r 1 v
Date�Q%Z _Cnntraclor A7y7_ q pp''rAA 9 r gU
am �< IL/T� /O�ZI, ptyl Vl 11ON .
¢ R w¢ OWNIi R-tl UILDCR DECLARATION CI I ION
K 1 MISC.- REFER TO ORD
w 3:3 I hereby affirm that I am exempt from the Contractor's License VALUATION " SIFT.
0 m
F'u o j law for the city
or o reason.(Sec.requires
a,tlusinessand Professions PERMIT ISSUANCE �. 6.00 m '
Code: e,d city or county which structure.
permit to umsuanc ,alaltso H '
¢ ¢Q improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NO. - ELEC.
in
- DLL requires the applicant for such permit to Elea signed statement that TOTAL PERMIT TO
R
$ he is licensed pursuanl to the provisions of the Contractor's License "
i F a i- Law(Chapter 9(commencing with Section 7000)of Division 3 of the //)1
¢ Business and Professions Code)or that he.is exempt therefrom and OTY. PLUMBING PERMIT FEE rl� P002L
W F o the basis for the alleged exemption.Any violation of Section 70315 STORIES TYPE CONSTR.
A. g'^ by any applicant t'or a permit subjects the applicant loa civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mom than five hundred dollars(5500).):
❑ 1,asowner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCCGROUPRES.UNITS
their solc.conipensation,will do the work,and the structure is not
Mended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Comment,',License Law dues not apply to an owner of
property who builds or,improves thereon,and who does such work FIXTURES-PER TR AP 4.00 SO,FFLFLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
nrcnts vcc not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-.1INC.4 OUTLETS.4.00
or ino
i p. vemenl is sold within one 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 im- RES IND' CON PB' ` Other
prove for purpose of sale)- INDUSTRIAL WASTE INTER. 20.00 Icy
❑ 1,as owner of the property,am exclusively contracting with ,Lr❑ ❑ ❑ ❑ ❑
licensed contremon to emm ura"to, moject(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 .ASSESSORS PARCEL NO-
and Professions Code:The Contractor's License Law does not apply -
to an owner of property who builds of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a eontmcrad0 licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO. `
0 lam exempt under Sec.-,B,&P.C.for.this
WATER HEATER W/VENT 4.00 -
reason
Owner - Date - WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO,
WORK ERS'COMPENSA"I ION DR.CLARA'I'[ON WATER TREATING EQUIP. 4.00
I hereby affirm dist I have a certi brine of consent to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified I ,
co iy t •reel'(Sec,3800,1 [,.C.l.-n
o 11 y G96YJXQSG,f(>?wTv-/'.ffa'yfo� f d1I91'anf11.1
❑ Certified cop is Ilnr_eby furnished. - FIRE SPRINK ENERGY T 24
Z Z �r Certified Y filed p Clicity pectins division. ,
FO A(,(;licaot / �T'yns MISC.- REFER TO ORD. Y ❑ IN C] Y ❑ N❑
rnPERMIT ISSUANCE 6.00 FLOOD ZONE A.Luc:
� � CIi R'I'I F'ICATIS P Ii XIiMPI'ION PROM WORKERS'
LU _ COMPENSATION I NSURANCE PLG.CONTR. LIC.NO. PLG.
d o ('Phis section need not be completed it' the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars(S 100)6,less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any manner so as to
V become subject to the Workcrs3Compensat ion Laws of California. SZ
U a Ude Applicant ALTER OR ADD TO MECH. 4.00 BUILDING � L_
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z_ emPOOD,you sliould become subject to the Worken'Cmnpensation 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 10000C.F.NL) 3.00
CONSTRUCTION LENDING ncENcv AIRHANDLING UNIT(OVER 10)"C.F.M.) 5.00 SEISMIC FEE V
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 '-
tile performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lendcr s Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
H, ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ablec-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 Said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit MECH.CONT. LIC.NO. MECH.
, OTAL TOTALJ.
Signature of Applicant/Contractor Date
OFFICE COPY