5703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
nDLLDING APPLICATION & PERMIT 5703
ADDRESS f
i 9 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
•, "AME OTY. ELECTRIC PERMIT FEE
• ` PHONE \
cA /NrnacroRs
t NAVE UTLETS-SWITCHES-RECEP 5.00/1.00
,
UC..O.
LIGHTING FIXTURES 5.00/1.00
r 'ONTRACTORS VAPPLIANCES-RESIDENTIAL 4.00
aDhDR E55 � '
I:z7Sto,10NE PANELS 5.00 DATE OF APPLICATION
APCHITECT SIGNS B.00 PLAN CHECK FEE P.C.NO.
DA'
e EN�wEER No. SIGNS TRANS. 3.00
An CH.OR ENG. PERMIT VALIDATION
AD On
SPECIAL CIRCUIT 5.00
ran rFEMP.METER OR POLE INS. 15.00
APPLIGAN is
ADDRESS MOTORS SEE FEE SCH.
12„ � 1 SERVICE CHANGE 10.00
44 0 0 z
I Foo LICI:N til D CONT RAC70RS DI CLAR V ION ( -
Ix mo U I hereby uNiTu that I m lianxd oder provisions of Chapter`I ISSUANCE GATE
r a w (cnmminculg with Section 70000 of D'v Is on 3 of the business and ( �� `P \ -f LDG. ELECT. PLG. MECH.
F H 2 Professions Cod, app m license I n full fo ce and fl c V x+11
soy Lmense Class 511 \umbQr' .I < - - .s _ ,. 1 - a'. -� -❑'..:
y.0 F Uric Contractor*' •. A a 1. -
a x s BUILDING PERMIT
a w a OWNER-BUILDER DECLARA'n ON INFORMATION
wo A MISC.- REFER TO ORD
g LL G 1 Ilnrchy oUlrn that I am exempt from the Contractor's License VALUATION S/FT-
~Fuo4 Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
in Code:Any city or county which requires a permit to construct,alter, 51 r
M2 ¢ a 0 improve,demolish,or repair any structure,prior to its isRlancu,also ELEC.CONTR. LIC.NO. ELEC. Z
G LL requires the applicant forsuch permit to file a signed statement that - TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
Fzr Law(Claque,9 lcummmocing with Suction 7000)of Division 1,111,
4 Business and Pmc,sions Code)or that he is exempt therefrom umd QTY. PLUMBING PERMIT FEE
5 i o
M F o .11mbasis for the alleged exemption.Any violation of Section 703 T.5 STORIES TYPE CONSTR.
oftinpplicaa lava subjects penalty ALTER-DRAIN&VENT-WATER (EA.) 4,00
1 ub4ot more than five htmdred dollars 15500).1: JL '
I• 9 I,as owner of the property,or my employees with wages as BACK FLOW PROTECT,DEVICE 2.00 OCC.GROUP RES.UNIT
thcirsolu compensation,will do the work,and ttur imcture-is not
inWaded or offered lis, sale(Sec. 7044, Business and Protessions' DRAINS-FLOOR,'ROOF,AREA,COND. 4.00 \
Code:1'IIo Contractor's License Law does not apply to an owner of
poYperty who builds or improves thereon,and who does suchlwork FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
Ihimself ar through his own employees.provid E;d thi11 such improve.
nents are not intended or offered for sale.-If.however,the building PAS-EA.SYSTEM-11NC.40UTLETS 4.00
or'hipravement is sold within one year of completion,:the'owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
bailer will have the huNcn of proving that he Aid nbl.huild.or,im- 5 IND CON PB Omer
.� prove for pup>ox of salc.l. a INDUSTRIAL WASTE INTER. 20.00 C) El ❑ 11O L as owner of the property,am exclusively'contracting with;
d .. licensed conra,cas to construct the project(Sec.7044,Business 1 LAWN SPRINKLERS- 1 INC 5.V.B. 5.00 ASSESSORS PARCEL NO,
hand 1 r sf scions(odeI li•Contr etoi-s Licenwla do`s rint apply •-
to am o n•r� of properly who builds or Improves lhcr�rlmal who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 I ra
ntcls for such projects with a c r tra-tons)licensed pursuant to
tirCm t agar's License Law. SEW ER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
.. O I am exempt under Sec. ,B.&P.C?I'DF this WATER HEATER W/VENT 4.00
-a rIP3on •wVF
Owrllel74 Dat,. WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
"W WORKERS-COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
lyhereby affirm Chet 1•I�avc u certi0uatc of umsent to self Inure. I ZONING
- or.b ecatificale of Worker3r Compensation Insurance,or a2<rtified ENG.SITE NO.
pyth sf Se R 0„1:abC.)
hc, NL� ra1A}� St-oxer-
'77171
A-F Fa)•ne]...., '_ /41J .a_ _
-0-
� `7D CntOed copy R fmraby'Furnished t -- J 4, }; ,•,�-- .'N. FIRE SPRINK ENERGY T-24
a Z Zt
Certified xlpy Is:fihd I thceutyr .. ion divivon 1 -
.{ p \ ;�- MISC."- - ,{ REFER TO ORD: r❑' N❑ Y ❑ N❑
'¢ y CERTIPICATEOF EXIT MPTION FROM% iKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
LU COMI'IiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
✓ n• O El his section need not he complete) if tirepermit is for one TOTAL Y E] NE] Y❑ N❑
D Z hundred dollar,IS 100)or less.)
U O I ccrlily that in the performance of the work for which Ihis per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any rummer so as to
' U become subject to the Workers'Compensation Laws of California. BUILDING
W Dntu Applicant ALTER OR ADD TO MECH. 4.00
} to NOTICE '10 APPLICANT: if,after making this Certificate of Ex-
r Z emlption,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 provision or this permit shall be dee red 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
I he eby affirm Ihat Ihere is o construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perlirrmance of the work for which this permit is issued(Sec. ROFILM
30?7,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lenders
NameHEATING UNIT(OVER 100,000 B.T.U. .50
Lender's a )7ELECTRIC
'I[certily that have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
infbrinution is correct I agree to comply with all city and manly PLUMBING
oreinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
Imreby muthonic representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCI-C. MECHANICAL
ubS'e-meti
noned property for inspection purposes.
I(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this pert. MECH.CONT. LIC.NO. MECH.
, ?T TOTAL TOTAL
Sig oureof Appligart/Contractor ,11' Date
INSPECTOR COPY