3607 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I NTIFICATION PERMIT NUMBER
6UILnl G APPLICATION & PERMIT 3607
vAoo^ ��0 / j /��/- 46
L ING - ELECTRICAL-PLUMBING -MECHANICAL v
OwIY R'S PLAN CHECK VALIDATION
NAft QTY. ELECTRIC PERMIT FEE
• / &NE
NOMI Too IS OUTLETS-SWITCHES-RECEP 5.00/1.00
r` d/
i rc.No LIGHTING FIXTURES 5.00/1.00
oNTR CTORS APPLIANCES-RESIDENTIAL 4.00
aooR S
t / PHON PANELS 5.00 DATE OF APPLICATIO
RCHITECi SIGNS 6,00 PLAN CHECK FEE P.N C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
i,P EMP.METER OR POLE INS. 15.00
4PPu6ANrs MOTORS SEE FEE SCH. J
qOO ESS
v // -� SERVICE CHANGE 10.00
ao o LICENSED CON'I'RACTORS DECLARATION S
If' G p 1 frothy aRirnl that I am licensed under provisions of Chapl•r 9 ISSUANCE DATE
H 'L ( Omlll riving With Section 7000)of Division 3 of the Busines Jnd BLDG, ELECT. PLG. MECH.
F D Z Professions Code pnd,myp��Iiaense Is In tell fore.and f ct ❑ ❑ ❑ ❑
z o L tens Iass�2St_I m Number
I.O z o Ole ./ Contractor_. _
i
a y f tea. BUILDING PERMIT
•¢ w OWNER BUILDER DLCLA nP N .-.l -�. INFORMATION-- -
oA MISC.- REFER TO ORD
X g A.y 1 hereby aft irm that 1 am exempt from the Contractor's License VALUATION
F LL o 4 Law for tire following..rime.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permll to consnrucl,alter,
QQ¢ 2O Improve,denmllsh,or repair any structure,prior to Its issuance.also ELEC.CONTR. LIC.NO. ELEC.
0 M requires the applicant for such permit to file a signed statrmmll that TOTAL PERMIT r0
whe is licensed pursuat to the provisions of the ContracloLs License
H. I Law(Chaplcr9(conuntncing with Section 7000)of Division 3o11hc �LL
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Anv violation of5ection 7031.5 STORIES TYPE CONSTR.
aim by any applicant fur a permit subjects the applicant in a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not noun,than five hundreA dollars 14500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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,CONE). 4.00
Code:The Contractor's Licanst Law dots not apply to un owner of
property who builds or in,o ves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL-ACREAGE
himsell'or through his own employees.Provided that such improve. .
ments are not intended or olfered for sale.IL however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
/ or improvemmrt is sold within one year of completion,the owner-
buildcr will have the burden of proving that htdid not huild or in. GAS- EA.SYSTEM-OVER 4 (EA-) 1-00 BUILDING USE
Prove for purpose ofsalc). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB 01her
111,as owner of the property,ane exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project (Sec. 7044, Business LAWN SPRINKLERS; 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO-
and I'rufessions Code.Thr 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 contraclorls)licensed pursuant to
p mu Cont mcmr's.Licenst l.aw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam cscnipl under,Sec.-,BAII C.lirt this WATER HEATER W/VENT 4.00
reason
Dale r Owner WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORK I!RS'COMIIENSA'[ION DEC RATION WATER TREATING EQUIP. 4.00
I htreby Alfieri that I have"v certificate of n sent to sel4innr ,
or a certificate of,Wbrkrrs'Compensation Inst ante or certif I ZOwNG ENG.SITE NO.
c
opythem 8yp.0,Lan C.I.
Policy NS l un"In
O ❑ Certified copy is hereby fur . d, FIRE SPRINK ENERGY T 24
'^ Z 2
ore,rtified copY. �fi ed- the n inspection division. MISC.- REFER TO ORD.
O Appi - Y ❑ N❑ Y ❑ N❑
cc L4 CERTE' S P X'F..MPIION FROM WORKERS, PERMIT ISSUANCE 6.00 FLOOD 20NE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTE. ❑C.NO. PLG. Y❑ N❑ v ❑
Z ffNEI sedum nerd not be completed it ha e
' the per ix nc TOTAL
hundred dollars IS 100)or Itss.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
lL F- mit is issued, I shall:not employ any person in any mannerso as to
Ow became subject to the Workers'Connpensation Laws of California. BUILDING
a Umt APPlicant ALTER OR ADD TO MECH. 4.00
} rA NOTICE TO APPLICANI: IL after nnakmg this Cet Wcatr of Ls-
F" Z eruption,You should become subject to lire Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must torthwithcomply with FEE
U wch provisions or this pennil xhall be Acenned revoked. AIR HANDLING UNIT(TO 10,(10DC.F.M.) 3.00
I
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 ISMIC FEE
t 1 hereby uftirnn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the prH..nnunec of the work for which this pennil is Issued Isec ICROFILM
3097.C,,CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
a. Lender's NaIrce ELECTRIC
I ,rtify than 1 have ,ad IN,appliculion and sLte than the above VENTILATION FAN (SINGLE) 3.00 -
information is unreel. I agr a to comply with all city and comely PLUMBING
ordinances and stale laws relating to building construction, and'_ BOILER-COMPI3 H.P.or 100,000 B.T.U.1 4.00
hereby authorim representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-Intntioned property Ibr no,scton purpo n.
(N'e) aFrce m sa e, Iidemm'y and keep harmless the City of MISC. - REFER TO ORD.
Cupertino Spin sLAa lime .ju merits, costs and expenses which CONST.TAX
may bran way rue agui t said City in consequence of the PERMIT ISSUANCE 3.00
granting o Ih coif. .CONT. LIC.NO. MECH.
OTAL TOTAL
_Signa neo pplica /CoNractA Date
tt INSPECTOR COPY
f, •x l