5695 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT I. PERMIT NUMBER
BUILDING 5695
aDURESS c
1J BUILDING -ELECTRICAL-PLUMBING+MECHANICAL 1
(92
O NLR'S J PLAN CHECK VALIDATION
Nome r .• ELECTRIC PERMIT FEE
PHONEr (•M,I G I CITY,.1
CONTRACTORS
NAME
\
NAME LETS-SWITCHES-RECEP 5.00/1.00
LIC.NO, Q LIGHTING FIXTURES 5,00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL4.00
ADDRESS
PHONE PANELS 5.40 DATE OF APPLICATION
' ARCHITECT' - PLAN CHECK FEE P.C.NO.
OR
SIGNS
6.00
ENGINEER
i LIC.No. SIGNS TRANS. / 3.00
ARCH.OR ENG. 5:0D
/ ' PERMIT VALIDATION
ADORES
S SPECIAL CIRCUIT ( - " �. '�
zlv TEMP.METER OR POLE INS. 15.00
AVPLICANT'$ �
yam. j
APPLICANT
' FEE SCH. ! D
MOTORS SEE N
ra� A. SERVICE CHANGE 10.00
, 0
FE 2 0
H O o LICI!NSIiU CUN'I'RACTORS DEChA RA'f10N
G U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Nz "' Iconvnencin 'Th Section 70001 of Division 3 of the Business and
4 a g l BLDG. ELECT. PLG. MECH.
H N z professions Co{I� an I license is in full forcaatW eIfec�t
Licens•CP,rtssSe'S7 Lie_Num r - ,i^ - . - ❑ ❑ ❑ _ _❑
o �.. Uhtc ��RJ •i Contractor -l. 1 r. '� 1 t _ `t _
a Y E - BUILDING PERMIT
¢ 4 OWNER-BUILDER DECLARA'f1 ON
F, w v INFORMATION
K
;
w t I hereby affirm that 1 oar exempt Dont tire License MISC.- REFER TO ORD
License
LLO4 Law to,the fallowing reasom(Se,703 L5,Businessand professions PERMIT ISSUANCE 6.00 VALUATION $/FTm.
m O -r Code:Any city orcounty WhiclrrequiresupermittoconslruL
caller. ro SSC•
rt2 < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. J
a, requires the applicant for such permit to file a signet)statement that TOTAL PERMIT TO
n w he is licensed pursuant to the provisions of the Contractor's License (�
r z a Law(Chapter 9(commencing with Section 7000/of Division 3 ofthe
Business and Professions Code)or that he is exempt then �
efrom and QTY. PLUMBING PERMIT FEE 1��.1L7T
¢ r O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3� by any applicant for a permit objects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of Out more than five hundred dollar,($500).):
C, I,as owner of the Irmperty,or my employees with wages., BACK FLOW PROTECT. DEVICE 2:00 OCC.GROUP RES.41rvrt5
their sole com pensution,will-do the work,and tlw Mmctrre is mol
intended or offered for sale (Sr, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code TItTCoiurvc Fir s-LicJnnse Law does not apply loan owner of
Properly who builds or imp ioves thereon,olid who doessuch work F IXTUR ES-PER TRAP 4.00 - SO.FT FLOOR AREA TOTAL ACREAGE
!. himself or through his own employees,provided that such improve-
ments are not intended or Offered for sale ll',however,the building GAS,-.EA.SYSTEM-1 INC.4OUTLETS 4.00
Or improvement is sold_within one year of completion.the owner- GAS-'EA.SYSTEM-OVER 4 IEA.) 1.00 " BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON- PB - Omer
prove for purpose of sale.). I . INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
\ licensed contractors m construct the projecb(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
\ and Pomessim,Code;]'he Cairtraetor's License Lawdoes not apply '
to an owner of DrunarlY who builds or Inrproves'ihereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such pm!"is with a contraclons)licenstid pursuant to
tireComructorisLicense Law. SEWER-SANITARY-STORM EA..2OOR/B.00 TRACT NO. PARCEL NO.
❑ lamexemptunder Sec. ,B.&P.0 or mis WATER HEATER W/VENT 4.00
reasup
+.wa..,�.• 'Fier '' Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.. 4.00
.t WORK S'GOMpFNSAT'ION DECLARATION WATER TREATING EQUIP
6T, i r...
art1 hereby off that I have praozicate ofconsent o set f-inmm,
a mrtif Cate I'Workers'Compensation Insuruncc,ur v cerulictl ZONING ENG.SITE NO. -
,. . I copy Ihereol(S TR00 I Sb. .)
P.lieyNo c5 Y sl;lt ny nity SCRT' IM( ....
b" O" .0 CertifieQ bpy fie h"c"furnished. r ( 'w,�. .. �''e 'r'e�. - FIRE SPRINK ENERGYT-24
Z 2 ❑�'[ertfi S op y s filed'willr the city urspectmFi dtvislmr. + 1
O Anal -.not MISC.- 'REFER TO ORD. Y ❑ N❑ Y❑ N❑
M y CERTIFICA"IFOE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
W > COhIPENSAT'ION INSURANCE: PLG.CONTR. LIC.NO. I.G.PCL 0
CL Z (This Section need not be completed if the permit is for one TOTAL Y❑ N❑ v ❑ N❑
hundred dollars IS 100)or les.)
U O 1 really that in 01e performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued,I shall not mnploy any person in any mannerso as Ice
O w become subject to me Workers''Compensiumnlaws of California. BUILDING
a Uatc Applicant ALTER OR ADD TO MECH. 4.00
} rn NOTICE TO APPLICW'1': If,after making this Certificate of Cx-
F Z emption,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 provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M-) 3.00
CONS"l'RUCI'ION LENDING.AGENCY AIR HANDLING UNIT(OVER 10)000C.F.M.) 5.00 SEISMIC FEE
I.hereby affirm th3f there is a construction lending agency for EXHAUST HOOD(WITH:DUCT) 2.00
the perl'orriance of the work for which this permit is issued(Sec MICROFILM
3097,CIYC). - - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's NAddreame ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
s information is iorrect. 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
above-mentioned property for inspection purposes.
(We) agree to ares, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
miry in any way accrue against said City in consequence of the
granting oftbis parrot). MECH.CONT. LIC.NO. . MECH.
Vt , r� -(-�u lCJS TOTAL TOTAL �.GU
Signature of A pplicant/Contractor Uate
INSPECTOR COPY