7154 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
DAPPLICATION & PERMIT
TADRESS .r
ADDRESS
/Q� nI R6 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7154
OWNER'S PLAN CHECK VALIDATION
�( NAME �'J,,ll,,��,, �A/� RR� "�yy CITY. ELECTRIC PERMIT FEE
/I1� r•y 13411,a - PHONE
CONTRACTORS
•1 NAME 510 UTLETS-SWITCHES-RECEP 5.00/1.00
'Lj CU(t/ZL-a1 To.No. 472_79,307& LIGHTING FIXTURES 5.00/1.00
CADDOEssRESS Rs Z��9.3133 PPLIANCES-RESIDENTIAL 4.00
29233 PHONE / PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECKFEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
ARCHESS OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 1%
APPLICANT -3 MOTOR SEE FEE SCH.
�L..
SERVICECHANGE y>'10.00 r
woo LICENSED CON TRACTORS DECLARATION
a U 1 hereby affirm that I mm licensed under provisions of Chapter 9 r�'�'-" f r ISSUANCE DATE
zw (commencing with Section 7000)of Division 3 of the Business and ELECT. PLG. MECH.
m i 1'rofessinns Cndc,pntlf I license
is in full force ❑ ❑ ❑
z o w - License CI ss ` LIC..Number JJ
O D- w
Date Contractor !
m s < ^- 1 BUILDING PERMIT
R w OWNL'R-B UILDIiR DECLARATION RnTION INFORMATION
AOA MISC.- REFER TO ORD
w 3 LL w I hereby affirm tiros I am exempt from the Contractor's License _ VALUATION SIFT.
Hu04 Law for the following reason.(Sec.7031.5.liusinessand Professions PERMIT ISSUANCE 6.00
Code Any city or county which requires a permit to constor Later, -
w > p p' y r to its issuance,also ELEC.CONTH. G LIC.NO.,
SE a4 Q improve,demolish,or re air an structure,poo �. ELEC. fD
DLL requires the applicant for such permit to file a signed statement that ' TOTAL• �• / MIT TO
a w m he is licensed pursuant to the provisions of tire PER
e Contractor's License IT
HZQLaw(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT_ FEE
EE 0 the basis for the alleged exemption,An
g p he violation t to a cion per
L$ STORIES TYPE CONSTR.
s ? by any applicant fora permit subjects the toacivil penally ALTER-DRAIN -WATER (EA.) 4.00
. of not nmrc than five hundred dollars(8500).): '
❑ 1,as owner of the property,or my employees 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 ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'fire Contractor's License Law does not apply to an owner of
properly who builds or illi prove,thereon,and who docs such work FIXTURES"PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
rc
meal,anot intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement 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-
prove for purpose of sale.). TRIAL WASTE INTERRES IND CON PB Omar
❑ I,as owner of the properly,am exclusively contracting with INDUS . 20.00 ❑ ❑ ❑ ❑ ❑
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'he C.TDa,tor4 License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a eontractorls)licensed pursuant to
f the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
.I' ❑ I oto exempt under Sea ,B.&P.0 for this WATER HEATER W/VENT 4.00
A reason
c Owner r Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
1 '
WORKERS'COMPENSA'HON DIiCLARA'I[ON WATER TREATING EQUIP. 4.00
1 hcwbyiatlirm that 1 have a certificate ofconum to self-insure. ZONING ENG.SITE N0.
or a eerlifihate of Workers' pensalion Insurance,or a certified
copy there"ppjj(�Sy•c.�y�p�
Polity NaLK..�_L�CcJ� any" jg?) i- 7NSV<�AV(!
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
z•Zo ❑ Certifd copy is ppp th the city inspection division. MISC.- REFER TO ORD.
O Applicant v ❑ N❑ Y ❑ N❑
CrN CER1I ICA IF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU COhll'EN$A1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
r 0- Z ('Phis section need not be v mpleted if the permit is for one TOTAL Y❑ N❑ y ❑ N❑
hundred dollars($100)or Ic.J
U OI certify'that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U becomesubject to the Workcrs'Colepen,stiun Laws of Culilinlid.
0 y Datc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,site,making this Certificate of Ex-
Z em pt on,you should become subject to tire er+
e Work '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 declined revoked. AIR HANDLING UNIT(TO 10,00DC.F.M.) 3.00
CONSTRUCTION LFNDING AGENCY AIR HANDLING UNIT(OVER 10=1 .F.M.) 5.00 SEISMIC FEE
I hcrcby .Minn [flat thr a is a construction lending agoney for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Names ELECTRIC �TQ
1 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
ordinances and state laws relating to building construction, and BOILER-COMP(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
ahovc-mentioned properly 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue gains l said CI in consequence of the
gramingofthis per MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signal r fApp I 0RUIC.Muclo, I Date
INSPECTOR COPY