6934 (3) ,APPLICANT T&FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION PERMIT NUMBER
F BUILDING APPLICATION & PERMIT ���
AODREss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwrvE 'S PLAN CHECK VALIDATION
NAME�. YRDNE CITY, ELECTRIC PERMIT FEE
3.�
CONTHRILCTOR3
NAME � UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
'caows PPLIANCES-RESIDENTIAL 4.00 '
cdNrynol Ess
ONE PANELS 5.00 N" DATE OF APPLICATION
ARCHI I SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
tic.No. SIGNS TRANS. 3.00
ARCH.Ess ENc' SPECIAL IRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANTS d' MOTORS SEE FEE SCH. V J f
ADDRESS (7/Y�
SERVICE CHANGE 10.00 y
o ¢ z ti O/O S-,
r o O LICENSED CON I'RACTORS DECLARATION
<U. I hereby affirm Ihut I any licensed under provisions of-Chapter 9 I 'ISSUANCE PATE
H G w (commencing'with Section 7000)of Division 3 of the Business aaJ BLDG. ELECT. PLG. MECH.
F N z Professions Code,a y license is in full force'i cLt ❑ ❑ ❑ El
O.w-0 license Class Lic.N tuber /
g z r- w/ Uate Contractor
¢ y "s BUILDING PERMIT
¢ ¢ w ¢ OWNGR-BUILDER DECLARATION INFORMATION
e. 0 a 0 MISC.- ''t REFER TO ORD
w 3 LL r I hereby al firm that I am exempt from the Contractor's License VALUATION $/FT.
Hu0� Law filo the following reason.ISec.703L5,Businessland Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to cumstr ct,alter, -Q
QQ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. 'LEC +
n m u ,,,Lima the upplicinl for such permit In filen slimed statement that TOTAL CA PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(commencing with Section 7000)o'Division3ofthe S`F1/J
a If usiness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
F
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ya
by any applicant fora permit subjects the applicant loacivilpenally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.OQ OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the s'truclure is not
intended or offend for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00''
Code:"The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXT ,RES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employecs,provided that such improve-
merits ore not intended or offered fol sale If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
lnprovmneut is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of proving that Int b
did not build or int . . .
- RES IND CON PB Omai
pnmu 1for,as owner
of tile.). INDUSTR IAL WASTE INTER. 20.00 ❑ I] ❑ ❑ ❑
❑ d as owner of the property,he rojectiv Se .7044,1ins with
licensed contractors to construe, the project(Sec 7044,Business LAW N'$PRINKLE RS- 1 INC 5 V+B: 5.00 ASSESSORS PARCEL NO.
and itProfessions Code:The who
Contractor's improv Law does not apply
to an owner of property who huilJs or improves thereon,and who LAWN SPRINKLERS-OV,E R'5(EA.) 1.00
contracts for such projects with a contraclor(s)licensed pursuant to
the CoJumcm�s License Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO, PARCEL NO.
❑ am,exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dude WATERSYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORRIiRS'COMPHNSn'I'ION Uf!CI,nRn'nON WATER TREATING EQUIP. 4.00
C/
1 hereby+tfirm that I have a certificate of Consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerlifiud
copy tlmrcuf(Scc.3800,Lab C.)./J
'Policy No. Company./'S��/�u�/ '-d�
O � Certified Copy is hereby lurnis .h J. FIRE SPRINK t ENERGY T 20
� l'
z - Cetlifi copy filed wit Lfeity inspection division. MISC2 A pplic'"' .- REFER TO ORD. Y N Y N[:]
T CER7114C 'EUI'IiXIiMP1'ION FROM W� PERMIT ISSUANCE 6.00 Cbl FLOODZONE A.L.U.c.
LU J COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d r. Y N Y N�
0 ('This' section Lived not be completed it the permil is for one TOTAL TV
LDZ hundred dollam(S 100)or less.)
U O 1 certify(hal in the performance of the work for which this per, QTY, + MECHANICAL PERMIT FEE FEE SUMMARY.
LL H mil is issued,I shall not employ any person in any....Liner s0 as to
U become subject to Lite Workers'Compensation Laws of California. ��11
O w Dye n Ocm BUILDING vU S?)
La. pp ALTER OR ADD TO MECH. 4.00 - -
} w NO1'ICIi 1'0 APPLICANT: If,after making this Certificate of Lis-
eruption,you Should hacome 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 10)"C.F.M.) 3.00
CONST RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10(MC.EM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perorman,, of the work for which this permit is issued(Sac. MICROFILM
3097,Civ.CJ. - HEATING UNIT(TO 100,000 B.T.U.) 4.00
LenderAddress Name
lornimHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
LaWer's (�
I certify that I have read this application and state that the above VENTILA ON FAN (SINGLE) 3.00 r /
• information is correct. I agree to comply will,all city and county PLUMBING !P
ordinances and state lows relying to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby author((c mpresematives of this city to enter upon the BOILER-COMP(Over 100,000 BTU),SEE FEE SCH. MECHANICAL
above-orentioned properly for inspection purposes.
(We) agree to save, mideomify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judsmel is and expenses which PERMIT ISSUANCE 3.00 JTe CONST.TAX
may in any way accrue against v' .t inconsequence of the
Pon In of this per rfi. MECH.CONT. LIC.NO. MECH.
V TOTAL 7 U
Signa urc Applicant/C ntractor Uatc / TOTAL
INSPECTOR COPY