C6606 APPLICANT TO FILL IN INFOR ATION WITHIN RED LINES - USE BAPOINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICAT 'y ' h ERMIT NUM R
1• BUILDING APPLICATION & PERF
ADDRESS 66.06
OAkvlEv�tHCuPT BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
X OWNER'S N CHECK VALIDATION
NAMEQTY. ELECTRIC PERMIT FEE
7r ` }/AVIS PHONE S 15131 ._
CONTRACTOR s'. 2 OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC,NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESSRESSPPLIANCES-RESIDENTIAL 4.00
_ AD
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
LIC,No. SIGNS TRANS. 3.00
ARC Ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION-
zIP TEMP.METER OR POLE INS. 15.00
APPLICANT s
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
00 LICENSIi1)CONTRACTORS DECLARATION
< U;_ I hereby of Oran cool I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F s'z 1'rofaslons Code,and my license is in lull force and effect. ❑ ❑ ❑
N
`z o m- License Class Lia Number
O as w Date Contractor
F -'J
¢ y au J BUILDING PERMIT
CE 0 w ¢ OWNER-BUILDER DECLARATION
INFORMATION
o > - MISC.- REFER TO ORD
X g 4 m I hereby aft to that 1 am exempt tram the mess and Pr fessions VALUATION
u 0 j Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE $/FT.
- Code:Any city or county which requires permit tomnstruct,aIle" 6.00
)'rt ¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NQ ELEC.
ue
DLL ¢quires the applicant I'or such permit to file a signed statement that TOTAL / + PERMITTO
u w m he is licensed pursuant to the provisions of the Contractor's License
H z s- Law(Chapter 9(commencing with Section 700()of Division 3ofihe ��
x ¢o Business urd Professions Code)or that he is exempt therefrom end GTY. PLUMBING PERMIT FEE PV
M I-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam by any applicant for a permit subjects the applicant lox civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than rive hundred dollars(5500).):
❑ I,as owner )],the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUPRES.UNITS
s their sole compensation,will do life work,and the structure is not
intended or Offered forsale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
C(de:The Contractor's License Law does not apply to an owner of
pm Rerty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
_ meals are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4,00 /L �-
OF improvement is sold within one year of Co uldetion,the owner-
�R` builder will have the burden of proving that he did not buildor int- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
pov•for purpose of sale.). INDUSTRIAL WASTE INTER- 20.00 IND CON PB Omer
y` I,as owner of the property,an.exclusively contracting with ❑ ❑ ❑ ❑
r licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and Professions Code:The 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 pn,jedp with a nnntraaons)licensed pursuant to
the Contracmr's License Law. EWER-SANITARY-STORM EA.20011/8.00 TRACT NO. PARCEL NO,
CIIum exempt Under Svc._.B&P.0 far this WATER HEATER W/VENT 4.00
> rv,VO1
( Owner 1, Date WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKERS'COMNiNSAT ION DECLARATION WATER TREATING EQUIP. 4-00
1 hereby ulfirnn that 1 have a certilicat,of consent to scl4inwre' ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.L
Policy No. - Connpaly
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
r Z 2 ❑ Certified copy is riled with the city inspection division.
0 ApNicaut MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC y CER'I'IFICA'IE 01:EXEMPHON PROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCE! PLG.CONTR. LIC.No. PLG. v❑ NE] v ❑ NE]
['Phis section need not he completed if the pennit is for one TOTAL T
hundred dollars($100)or less.)
V U 1 certify that in tine performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any routine,so as to
U becomes object to the Worker5'Connpensatinn Lawsof CaIn..TOM.
iDate Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
>. Do NOTICE '10 APPLICAN 1': If,after making this Certificate of CC-
F Z cnq,l ion,you should necmnc suhj,et to the workers'Compensation APPLIANCE 4.00 PLAN CHECK
v provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOCF.M) 3.00 / �
CONS"fRUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE , /3
I hereby affirm that there is a constnmtlon lending agency 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
LeamAddress
Lender's Nae
der's HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC`'
I certify that 1 have read this application and State mat the above VENTILATION FAN (SINGLE) 3.00
information is coned.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building con 'to"
and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 ✓
Iherebau
y thorise representatives of this city to entr upon the BOILER-COMP (OPOICKI,000BTU)SEEFEESCH. MECHANICAL
above-Thrltioned property for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in any way accrue against Said City in con Hence of the PERMIT ISSUANCE 3.00
gR."ng his permit MECH.CONT. LIC.NO. MECH.
1CaAL y, � Q _ L� TOTAL TOTAL
Signature of A pplicant/Contractor Date %
INSPECTOR COPY )